MEDICAID ELIGIBILITY MANUAL Revised 07/01/2026 1/1/2026 7/1/2026 1/1/2027 7/1/2027 $2,982 N/A $162,660 N/A $4,000 N/A $752,000 N/A $9,430 $9,430 $309 $309 $453.00 N/A $4,066.50 N/A $2,643.75 $2,705.00 $215.14 $215.14 per plate $678.44 $678.44 full pair $1,356.88 $1,356.88 $270.00 $270.00 for one $1,777.40 $1,777.40 for both $3,377.40 $3,377.40 Monthly Rate APPENDIX A- 2-i CHART OF INSTITUTIONAL LIMITS & TRANSFER OF ASSETS DIVISORS INSTITUTIONAL INCOME LIMITS Federal Maximum SPOUSAL IMPOVERISHMENT MAXIMUMS Federal Resource Maximum - Community Spouse Limit LIBERALIZED RESOURCE LIMITS Single Individual and Institutional Spouse Limit SUBSTANTIAL HOME EQUITY LIMIT Federal Equity Minimum Limit Used by DOM TRANSFER OF ASSETS DIVISOR RATES Eyeglasses -per occurrence for lenses, frames, dispensing fee Dentures Denture Repair - per occurrence Hearing Aids Daily Rate MEDICAID INCOME DEDUCTION MAXIMUMS Earned Income Disregard (Work Deduction) Community Spouse Monthly Maintenance Needs Allowance Other Family Members Needs Allowance (Living with CS or Dependent Child Under Age 18 - No CS) NON-COVERED MEDICAL EXPENSE LIMITS

MEDICAID ELIGIBILITY MANUAL Revised 07/01/2025 1/1/2024 7/1/2024 1/1/2025 7/1/2025 $2,829 N/A $2,901 N/A $154,140 N/A $157,920 N/A $4,000 N/A $4,000 N/A $713,000 N/A $730,000 N/A $8,300 $8,300 $8,300 $9,430 $272 $272 $272 $309 $427.50 N/A $439.50 N/A $3,853.50 N/A $3,948.00 N/A $2,465.00 $2,555.00 $2,555.00 $2,643.75 $216.30 $215.14 $215.14 $215.14 per plate $678.44 $678.44 $678.44 $678.44 full pair $1,356.88 $1,356.88 $1,356.88 $1,356.88 $270.00 $270.00 $270.00 $270.00 for one $1,777.40 $1,777.40 $1,777.40 $1,777.40 for both $3,377.40 $3,377.40 $3,377.40 $3,377.40 Monthly Rate APPENDIX A- 2-h CHART OF INSTITUTIONAL LIMITS & TRANSFER OF ASSETS DIVISORS INSTITUTIONAL INCOME LIMITS Federal Maximum SPOUSAL IMPOVERISHMENT MAXIMUMS Federal Resource Maximum - Community Spouse Limit LIBERALIZED RESOURCE LIMITS Single Individual and Institutional Spouse Limit SUBSTANTIAL HOME EQUITY LIMIT Federal Equity Minimum Limit Used by DOM TRANSFER OF ASSETS DIVISOR RATES Eyeglasses -per occurrence for lenses, frames, dispensing fee Dentures Denture Repair - per occurrence Hearing Aids Daily Rate MEDICAID INCOME DEDUCTION MAXIMUMS Earned Income Disregard (Work Deduction) Community Spouse Monthly Maintenance Needs Allowance Other Family Members Needs Allowance (Living with CS or Dependent Child Under Age 18 - No CS) NON-COVERED MEDICAL EXPENSE LIMITS

MEDICAID ELIGIBILITY MANUAL Revised 07/01/2023 1/1/2022 7/1/2022 1/1/2023 7/1/2023 $2,523 N/A $2,742 N/A $137,400 N/A $148,620 N/A $4,000 N/A $4,000 N/A $636,000 N/A $688,000 N/A $6,893 $7,107 $7,107 $8,300 $226 $233 $233 $272 $376.50 N/A $413.00 N/A $3,435.00 N/A $3,715.50 N/A $2,177.50 $2,288.75 $2,288.75 $2,465.00 $215.14 $216.30 $216.30 $216.30 per plate $678.44 $678.44 $678.44 $678.44 full pair $1,356.88 $1,356.88 $1,356.88 $1,356.88 $270.00 $270.00 $270.00 $270.00 for one $1,777.40 $1,777.40 $1,777.40 $1,777.40 for both $3,377.40 $3,377.40 $3,377.40 $3,377.40 Eyeglasses -per occurrence for lenses, frames, dispensing fee Dentures Denture Repair - per occurrence Hearing Aids Daily Rate MEDICAID INCOME DEDUCTION MAXIMUMS Earned Income Disregard (Work Deduction) Community Spouse Monthly Maintenance Needs Allowance Other Family Members Needs Allowance (Living with CS or Dependent Child Under Age 18 - No CS) NON-COVERED MEDICAL EXPENSE LIMITS Monthly Rate APPENDIX A- 2-g CHART OF INSTITUTIONAL LIMITS & TRANSFER OF ASSETS DIVISORS INSTITUTIONAL INCOME LIMITS Federal Maximum SPOUSAL IMPOVERISHMENT MAXIMUMS Federal Resource Maximum - Community Spouse Limit LIBERALIZED RESOURCE LIMITS Single Individual and Institutional Spouse Limit SUBSTANTIAL HOME EQUITY LIMIT Federal Equity Minimum Limit Used by DOM TRANSFER OF ASSETS DIVISOR RATES

MEDICAID ELIGIBILITY MANUAL Revised 07/01/2021 1/1/2020 7/1/2020 1/1/2021 7/1/2021 $2,349 N/A $2,382 N/A $128,640 N/A $130,380 N/A $4,000 N/A $4,000 N/A $595,000 N/A $603,000 N/A $6,832 $6,832 $6,832 $6,893 $224 $224 $224 $226 $347.50 N/A $353.00 N/A $3,216.00 N/A $3,259.50 N/A $2,113.75 $2,155.00 $2,155.00 $2,177.50 $362.79 $215.14 $215.14 $215.14 per plate $678.44 $678.44 $678.44 $678.44 full pair $1,356.88 $1,356.88 $1,356.88 $1,356.88 $270.00 $270.00 $270.00 $270.00 for one $1,777.40 $1,777.40 $1,777.40 $1,777.40 for both $3,377.40 $3,377.40 $3,377.40 $3,377.40 Eyeglasses - per occurrence for lenses, frames, dispensing fee Dentures Denture Repair - per occurrence Hearing Aids Daily Rate MEDICAID INCOME DEDUCTION MAXIMUMS Earned Income Disregard (Work Deduction) Community Spouse Monthly Maintenance Needs Allowance Other Family Members Needs Allowance (Living with CS or Dependent Child Under Age 18 - No CS) NON-COVERED MEDICAL EXPENSE LIMITS Monthly Rate APPENDIX A- 2-f CHART OF INSTITUTIONAL LIMITS & TRANSFER OF ASSETS DIVISORS INSTITUTIONAL INCOME LIMITS Federal Maximum SPOUSAL IMPOVERISHMENT MAXIMUMS Federal Resource Maximum - Community Spouse Limit LIBERALIZED RESOURCE LIMITS Single Individual and Institutional Spouse Limit SUBSTANTIAL HOME EQUITY LIMIT Federal Equity Minimum Limit Used by DOM TRANSFER OF ASSETS DIVISOR RATES

MEDICAID ELIGIBILITY MANUAL Revised 07/01/2019 1/1/2018 7/1/2018 1/1/2019 7/1/2019 $2,250 N/A $2,313 N/A $123,600 N/A $126,420 N/A $4,000 N/A $4,000 N/A $572,000 N/A $585,000 N/A $6,619 $6,832 $6,832 $6,832 $217 $224 $224 $224 $331.00 N/A $341.50 N/A $3,090.00 N/A $3,160.50 N/A $2,030.00 $2,057.50 N/A $2,113.75 $362.79 $362.79 per plate $678.44 $678.44 full pair $1,356.88 $1,356.88 $270.00 $270.00 for one $1,777.40 $1,777.40 for both $3,377.40 $3,377.40 Daily Rate MEDICAID INCOME DEDUCTION MAXIMUMS Earned Income Disregard (Work Deduction) Community Spouse Monthly Maintenance Needs Allowance Other Family Members Needs Allowance (Living with CS or Dependent Child Under Age 18 - No CS) Monthly Rate APPENDIX A- 2-e CHART OF INSTITUTIONAL LIMITS & TRANSFER OF ASSETS DIVISORS INSTITUTIONAL INCOME LIMITS Federal Maximum SPOUSAL IMPOVERISHMENT MAXIMUMS Federal Resource Maximum - Community Spouse Limit LIBERALIZED RESOURCE LIMITS Single Individual and Institutional Spouse Limit SUBSTANTIAL HOME EQUITY LIMIT Federal Equity Minimum Limit Used by DOM TRANSFER OF ASSETS DIVISOR RATES Hearing Aids NON-COVERED MEDICAL EXPENSE LIMITS Eyeglasses - per occurrence for lenses, frames, dispensing fee Denture Repair - per occurrence Dentures

MEDICAID ELIGIBILITY MANUAL Revised 07/01/2017 1/1/2016 7/1/2016 1/1/2017 7/1/2017 $2,199 N/A $2,205 N/A $119,220 N/A $120,900 N/A $4,000 $4,000 $4,000 $4,000 $552,000 N/A $560,000 N/A $6,250 $6,405 $6,405 $6,619 $205 $210 $210 $217 $322.50 N/A $323.50 N/A $2,980.50 N/A $3,022.50 N/A $1,991.25 $2,002.50 N/A $2,030.00 LIBERALIZED RESOURCE LIMITS Federal Maximum SingleIindividual and Institutional Spouse Limit Monthly Rate Daily Rate APPENDIX A- 2-d CHART OF INSTITUTIONAL LIMITS & TRANSFER OF ASSETS DIVISORS INSTITUTIONAL INCOME LIMITS SPOUSAL IMPOVERISHMENT MAXIMUMS Federal Resource Maximum - Community Spouse Limit Other Family Members Needs Allowance (Living with CS or Dependent Child Under Age 18 - No CS) SUBSTANTIAL HOME EQUITY LIMIT Federal Equity Minimum Limit Used by DOM TRANSFER OF ASSETS DIVISOR RATES MEDICAID INCOME DEDUCTION MAXIMUMS Earned Income Disregard (Work Deduction) Community Spouse Monthly Maintenance Needs Allowance

MEDICAID ELIGIBILITY MANUAL Revised 07/01/2017 1/1/2014 7/1/2014 1/1/2015 7/1/2015 $2,163 N/A $2,199 N/A $117,240 N/A $119,220 N/A $4,000 $4,000 $4,000 $4,000 $543,000 N/A $552,000 N/A $5,700 $5,920 $5,920 $6,250 $187 $194 $194 $205 $316.50 N/A $322.50 N/A $2,931.00 N/A $2,980.00 N/A $1,938.75 $1,966.25 N/A $1,991.25 LIBERALIZED RESOURCE LIMITS Federal Maximum SingleIindividual and Institutional Spouse Limit Monthly Rate Daily Rate APPENDIX A-2-c CHART OF INSTITUTIONAL LIMITS & TRANSFER OF ASSETS DIVISORS INSTITUTIONAL INCOME LIMITS SPOUSAL IMPOVERISHMENT MAXIMUMS Federal Resource Maximum - Community Spouse Limit Other Family Members Needs Allowance (Living with CS or Dependent Child Under Age 18 - No CS) SUBSTANTIAL HOME EQUITY LIMIT Federal Equity Minimum Limit Used by DOM TRANSFER OF ASSETS DIVISOR RATES MEDICAID INCOME DEDUCTION MAXIMUMS Earned Income Disregard (Work Deduction) Community Spouse Monthly Maintenance Needs Allowance

MEDICAID ELIGIBILITY MANUAL Revised 07/01/2017 1/1/2012 10/1/2012 1/1/2013 7/1/2013 $2,094 N/A $2,130 N/A $113,640 N/A $115,920 N/A $4,000 $4,000 $4,000 $4,000 $525,000 N/A $536,000 N/A $5,700 $5,700 $5,700 $5,700 $187 $187 $187 $187 $305.00 N/A $311.00 N/A $2,841.00 N/A $2,898.00 N/A $1,838.75 $1,891.25 $1,891.25 $1,938.75 LIBERALIZED RESOURCE LIMITS Single Individual and Institutional Spouse Limit Federal Maximum Monthly Rate Daily Rate APPENDIX A- 2-b CHART OF INSTITUTIONAL LIMITS & TRANSFER OF ASSETS DIVISORS INSTITUTIONAL INCOME LIMITS SPOUSAL IMPOVERISHMENT MAXIMUMS Federal Resource Maximum - Community Spouse Limit Other Family Members Needs Allowance (Living with CS or Dependent Child Under Age 18 - No CS) SUBSTANTIAL HOME EQUITY LIMIT Federal Equity Minimum Limit Used by DOM TRANSFER OF ASSETS DIVISOR RATES MEDICAID INCOME DEDUCTION MAXIMUMS Earned Income Disregard (Work Deduction) Community Spouse Monthly Maintenance Needs Allowance

MEDICAID ELIGIBILITY MANUAL Revised 07/01/2017 1/1/2010 1/1/2011 7/1/2011 $2,022 $2,022.00 N/A $109,560 $109,560 N/A $4,000 $4,000 $4,000 $500,000 $506,000 N/A $4,600* $5,700 $5,700 $151* $187 $187 $293.00 $293.00 N/A $2,739.00 $2,739.00 N/A $1,821.25 $1,821.25 $1,838.75 03/01/2003 - 02/07/2006 04/01/1999 - 02/28/2003 10/01/1993 - 03/31/1999 $3,100 monthly rate $2,600 monthly rate $2,000 monthly rate TRANSFER OF ASSETS DIVISOR RATES PRIOR TO 01/01/2010 Federal Maximum Single Individual and Institutional Spouse Limit Monthly Rate Daily Rate *The monthly transfer of assets rate of $4,600 and daily rate of $151 was in effect for 02/08/2006 - 12/31/2010. OBRA-93 Transfer Rates were in effect from 08/11/1993 - 02/07/2006. Monthly rates are shown below; partial month penalty periods did not apply to OBRA 93 policy. APPENDIX A-2-a Other Family Members Needs Allowance (Living with CS or Dependent Child Under Age 18 - No CS) Community Spouse Monthly Maintenance Needs Allowance CHART OF INSTITUTIONAL LIMITS & TRANSFER OF ASSETS DIVISORS LIBERALIZED RESOURCE LIMITS Federal Equity Minimum Limit Used by DOM TRANSFER OF ASSETS DIVISOR RATES MEDICAID INCOME DEDUCTION MAXIMUMS Earned Income Disregard (Work Deduction) INSTITUTIONAL INCOME LIMITS SPOUSAL IMPOVERISHMENT MAXIMUMS Federal Resource Maximum - Community Spouse Limit SUBSTANTIAL HOME EQUITY LIMIT

Appendix Page A-3-m COE-073- Children Age 6 to 19 HH Size 194% FPL 194% + 5% Disregard 143% FPL 143% + 5% Disregard 107% FPL (no 5% disregard) 133% FPL 133% + 5% Disregard 209% FPL 209% + 5% Disregard State Set Income Limit Limit + 5% Disregard 1 $2,581 $2,648 $1,902 $1,969 $1,424 $1,769 $1,836 $2,780 $2,847 $227 $294 2 $3,499 $3,589 $2,579 $2,669 $1,930 $2,399 $2,489 $3,769 $3,859 $306 $396 3 $4,417 $4,531 $3,256 $3,370 $2,437 $3,028 $3,142 $4,759 $4,873 $384 $498 4 $5,335 $5,473 $3,933 $4,071 $2,943 $3,658 $3,796 $5,748 $5,886 $462 $600 5 $6,254 $6,415 $4,610 $4,771 $3,449 $4,288 $4,449 $6,737 $6,898 $541 $702 6 $7,172 $7,357 $5,287 $5,472 $3,956 $4,917 $5,102 $7,727 $7,912 $619 $804 7 $8,090 $8,299 $5,964 $6,173 $4,462 $5,547 $5,756 $8,716 $8,925 $697 $906 8 $9,009 $9,241 $6,640 $6,872 $4,969 $6,176 $6,408 $9,705 $9,937 $775 $1,007 9 $9,927 $10,183 $7,317 $7,573 $5,475 $6,806 $7,062 $10,694 $10,950 $853 $1,109 10 $10,845 $11,125 $7,994 $8,274 $5,982 $7,435 $7,715 $11,684 $11,964 $931 $1,211 11 $11,763 $12,066 $8,671 $8,974 $6,488 $8,065 $8,368 $12,673 $12,976 $1,009 $1,312 12 $12,682 $13,009 $9,348 $9,675 $6,995 $8,694 $9,021 $13,662 $13,989 $1,087 $1,414 For more than 12, add: $507 for each additional person to increase the FPL. 13 14 15 16 17 18 19 20 $351 $374 $398 $422 $445 $469 $493 $516 2026 MAGI INCOME LIMITS EFFECTIVE MARCH 1, 2026 COE-088-Pregnant Women, COE-071 - Infants to Age 1, COE-029 Family COE-072 - Children Age 1 to Age 6 COE-074- Children Age 6 to Age 19 COE-099 - CHIP COE-075 - Low- Income Parents & Caretaker Relatives Use the chart below for the correct 5% disregard amount to use for households with more than 12 persons. HH Size 5% Disregard Amt $919 for each additional person to increase the FPL. $677 for each additional person to increase the FPL. $630 for each additional person to increase the FPL. $990 for each additional person to increase the FPL. $78 for each additional person to increase the FPL.

Appendix Page A-3-l COE-073- Children Age 6 to 19 HH Size 194% FPL 194% + 5% Disregard 143% FPL 143% + 5% Disregard 107% FPL (no 5% disregard) 133% FPL 133% + 5% Disregard 209% FPL 209% + 5% Disregard State Set Income Limit Limit + 5% Disregard 1 $2,531 $2,596 $1,865 $1,930 $1,396 $1,735 $1,800 $2,726 $2,791 $227 $292 2 $3,420 $3,508 $2,521 $2,609 $1,886 $2,345 $2,433 $3,684 $3,772 $306 $394 3 $4,309 $4,420 $3,176 $3,287 $2,377 $2,954 $3,065 $4,642 $4,753 $384 $495 4 $5,198 $5,332 $3,832 $3,966 $2,867 $3,564 $3,698 $5,600 $5,734 $462 $596 5 $6,087 $6,244 $4,487 $4,644 $3,358 $4,173 $4,330 $6,558 $6,715 $541 $698 6 $6,976 $7,156 $5,143 $5,323 $3,848 $4,783 $4,963 $7,516 $7,696 $619 $799 7 $7,866 $8,069 $5,798 $6,001 $4,338 $5,393 $5,596 $8,474 $8,677 $697 $900 8 $8,755 $8,981 $6,453 $6,679 $4,829 $6,002 $6,228 $9,432 $9,658 $775 $1,001 9 $9,644 $9,893 $7,109 $7,358 $5,319 $6,612 $6,861 $10,390 $10,639 $853 $1,102 10 $10,533 $10,805 $7,764 $8,036 $5,810 $7,221 $7,493 $11,347 $11,619 $931 $1,203 11 $11,422 $11,716 $8,420 $8,714 $6,300 $7,831 $8,125 $12,305 $12,599 $1,009 $1,303 12 $12,311 $12,628 $9,075 $9,392 $6,791 $8,440 $8,757 $13,263 $13,580 $1,087 $1,404 For more than 12, add: $491 for each additional person to increase the FPL. 13 14 15 16 17 18 19 20 $340 $363 $386 $409 $432 $455 $478 $501 2025 MAGI INCOME LIMITS EFFECTIVE MARCH 1, 2025 COE-088-Pregnant Women, COE-071 - Infants to Age 1, COE-029 Family COE-072 - Children Age 1 to Age 6 COE-074- Children Age 6 to Age 19 COE-099 - CHIP COE-075 - Low- Income Parents & Caretaker Relatives Use the chart below for the correct 5% disregard amount to use for households with more than 12 persons. HH Size 5% Disregard Amt $890 for each additional person to increase the FPL. $656 for each additional person to increase the FPL. $610 for each additional person to increase the FPL. $958 for each additional person to increase the FPL. $78 for each additional person to increase the FPL.

Appendix Page A-3-k COE-073- Children Age 6 to 19 HH Size 194% FPL 194% + 5% Disregard 143% FPL 143% + 5% Disregard 107% FPL (no 5% disregard) 133% FPL 133% + 5% Disregard 209% FPL 209% + 5% Disregard State Set Income Limit Limit + 5% Disregard 1 $2,435 $2,498 $1,795 $1,858 $1,343 $1,670 $1,733 $2,623 $2,686 $227 $290 2 $3,305 $3,390 $2,436 $2,521 $1,823 $2,266 $2,351 $3,560 $3,645 $306 $391 3 $4,175 $4,283 $3,077 $3,185 $2,303 $2,862 $2,970 $4,497 $4,605 $384 $492 4 $5,044 $5,174 $3,718 $3,848 $2,782 $3,458 $3,588 $5,434 $5,564 $462 $592 5 $5,914 $6,066 $4,360 $4,512 $3,262 $4,055 $4,207 $6,372 $6,524 $541 $693 6 $6,784 $6,959 $5,001 $5,176 $3,742 $4,651 $4,826 $7,309 $7,484 $619 $794 7 $7,654 $7,851 $5,642 $5,839 $4,222 $5,247 $5,444 $8,246 $8,443 $697 $894 8 $8,524 $8,744 $6,283 $6,503 $4,701 $5,844 $6,064 $9,183 $9,403 $775 $995 9 $9,393 $9,635 $6,924 $7,166 $5,181 $6,440 $6,682 $10,120 $10,362 $853 $1,095 10 $10,263 $10,528 $7,565 $7,830 $5,661 $7,036 $7,301 $11,057 $11,322 $931 $1,196 11 $11,133 $11,420 $8,206 $8,493 $6,141 $7,632 $7,919 $11,994 $12,281 $1,009 $1,296 12 $12,003 $12,312 $8,847 $9,156 $6,620 $8,229 $8,538 $12,931 $13,240 $1,087 $1,396 For more than 12, add: $480 for each additional person to increase the FPL. 13 14 15 16 17 18 19 20 $332 $354 $377 $399 $421 $444 $466 $489 Use the chart below for the correct 5% disregard amount to use for households with more than 12 persons. HH Size 5% Disregard Amt $870 for each additional person to increase the FPL. $641 for each additional person to increase the FPL. $596 for each additional person to increase the FPL. $937 for each additional person to increase the FPL. $78 for each additional person to increase the FPL. 2024 MAGI INCOME LIMITS EFFECTIVE MARCH 1, 2024 COE-088-Pregnant Women, COE-071 - Infants to Age 1, COE-029 Family COE-072 - Children Age 1 to Age 6 COE-074- Children Age 6 to Age 19 COE-099 - CHIP COE-075 - Low- Income Parents & Caretaker Relatives

Appendix Page A-3-j COE-073- Children Age 6 to 19 HH Size 194% FPL 194% + 5% Disregard 143% FPL 143% + 5% Disregard 107% FPL (no 5% disregard) 133% FPL 133% + 5% Disregard 209% FPL 209% + 5% Disregard State Set Income Limit Limit + 5% Disregard 1 $2,358 $2,419 $1,738 $1,799 $1,301 $1,616 $1,677 $2,540 $2,601 $227 $288 2 $3,189 $3,271 $2,350 $2,432 $1,759 $2,186 $2,268 $3,435 $3,517 $306 $388 3 $4,020 $4,124 $2,963 $3,067 $2,217 $2,756 $2,860 $4,330 $4,434 $384 $488 4 $4,850 $4,975 $3,575 $3,700 $2,675 $3,325 $3,450 $5,225 $5,350 $462 $587 5 $5,681 $5,827 $4,188 $4,334 $3,134 $3,895 $4,041 $6,121 $6,267 $541 $687 6 $6,512 $6,680 $4,801 $4,969 $3,592 $4,465 $4,633 $7,016 $7,184 $619 $787 7 $7,343 $7,532 $5,413 $5,602 $4,050 $5,035 $5,224 $7,911 $8,100 $697 $886 8 $8,174 $8,385 $6,026 $6,237 $4,509 $5,604 $5,815 $8,806 $9,017 $775 $986 9 $9,005 $9,237 $6,638 $6,870 $4,967 $6,174 $6,406 $9,702 $9,934 $853 $1,085 10 $9,836 $10,090 $7,251 $7,505 $5,425 $6,744 $6,998 $10,597 $10,851 $931 $1,185 11 $10,667 $10,942 $7,863 $8,138 $5,884 $7,313 $7,588 $11,492 $11,767 $1,009 $1,284 12 $11,498 $11,794 $8,476 $8,772 $6,342 $7,883 $8,179 $12,387 $12,683 $1,087 $1,383 For more than 12, add: $459 for each additional person to increase the FPL. 13 14 15 16 17 18 19 20 $318 $339 $361 $382 $403 $425 $446 $468 2023 MAGI INCOME LIMITS EFFECTIVE MARCH 1, 2023 COE-088-Pregnant Women, COE-071 - Infants to Age 1, COE-029 Family COE-072 - Children Age 1 to Age 6 COE-074- Children Age 6 to Age 19 COE-099 - CHIP COE-075 - Low- Income Parents & Caretaker Relatives Use the chart below for the correct 5% disregard amount to use for households with more than 12 persons. HH Size 5% Disregard Amt $831 for each additional person to increase the FPL. $613 for each additional person to increase the FPL. $570 for each additional person to increase the FPL. $896 for each additional person to increase the FPL. $78 for each additional person to increase the FPL.

Appendix Page A-3-i COE-073- Children Age 6 to 19 HH Size 194% FPL 194% + 5% Disregard 143% FPL 143% + 5% Disregard 107% FPL (no 5% disregard) 133% FPL 133% + 5% Disregard 209% FPL 209% + 5% Disregard State Set Income Limit Limit + 5% Disregard 1 $2,198 $2,255 $1,620 $1,677 $1,212 $1,507 $1,564 $2,367 $2,424 $227 $284 2 $2,961 $3,037 $2,182 $2,258 $1,633 $2,030 $2,106 $3,189 $3,265 $306 $382 3 $3,724 $3,820 $2,745 $2,841 $2,054 $2,553 $2,649 $4,012 $4,108 $384 $480 4 $4,487 $4,603 $3,307 $3,423 $2,475 $3,076 $3,192 $4,834 $4,950 $462 $578 5 $5,250 $5,385 $3,870 $4,005 $2,896 $3,599 $3,734 $5,656 $5,791 $541 $676 6 $6,013 $6,168 $4,432 $4,587 $3,317 $4,122 $4,277 $6,478 $6,633 $619 $774 7 $6,776 $6,951 $4,995 $5,170 $3,737 $4,646 $4,821 $7,300 $7,475 $697 $872 8 $7,539 $7,733 $5,557 $5,751 $4,158 $5,169 $5,363 $8,122 $8,316 $775 $969 9 $8,302 $8,516 $6,120 $6,334 $4,579 $5,692 $5,906 $8,944 $9,158 $853 $1,067 10 $9,065 $9,299 $6,682 $6,916 $5,000 $6,215 $6,449 $9,766 $10,000 $931 $1,165 11 $9,828 $10,081 $7,245 $7,498 $5,421 $6,738 $6,991 $10,588 $10,841 $1,009 $1,262 12 $10,591 $10,864 $7,807 $8,080 $5,842 $7,261 $7,534 $11,410 $11,683 $1,087 $1,360 For more than 12, add: $421 for each additional person to increase the FPL. 13 14 15 16 17 18 19 20 $293 $312 $332 $352 $371 $391 $411 $430 Use the chart below for the correct 5% disregard amount to use for households with more than 12 persons. HH Size 5% Disregard Amt $764 for each additional person to increase the FPL. $563 for each additional person to increase the FPL. $524 for each additional person to increase the FPL. $823 for each additional person to increase the FPL. $78 for each additional person to increase the FPL. 2022 MAGI INCOME LIMITS EFFECTIVE MARCH 1, 2022 COE-088-Pregnant Women, COE-071 - Infants to Age 1, COE-029 Family COE-072 - Children Age 1 to Age 6 COE-074- Children Age 6 to Age 19 COE-099 - CHIP COE-075 - Low- Income Parents & Caretaker Relatives

Appendix Page A-3-h COE-073- Children Age 6 to 19 HH Size 194% FPL 194% + 5% Disregard 143% FPL 143% + 5% Disregard 107% FPL (no 5% disregard ) 133% FPL 133% + 5% Disregard 209% FPL 209% + 5% Disregard State Set Income Limit Limit + 5% Disregard 1 $2,083 $2,137 $1,535 $1,589 $1,149 $1,428 $1,482 $2,244 $2,298 $227 $281 2 $2,817 $2,890 $2,076 $2,149 $1,554 $1,931 $2,004 $3,034 $3,107 $306 $379 3 $3,551 $3,643 $2,617 $2,709 $1,959 $2,434 $2,526 $3,825 $3,917 $384 $476 4 $4,285 $4,395 $3,158 $3,268 $2,363 $2,938 $3,048 $4,616 $4,726 $462 $572 5 $5,019 $5,148 $3,699 $3,828 $2,768 $3,441 $3,570 $5,407 $5,536 $541 $670 6 $5,753 $5,901 $4,240 $4,388 $3,173 $3,944 $4,092 $6,197 $6,345 $619 $767 7 $6,487 $6,654 $4,781 $4,948 $3,578 $4,447 $4,614 $6,988 $7,155 $697 $864 8 $7,221 $7,407 $5,322 $5,508 $3,983 $4,950 $5,136 $7,779 $7,965 $775 $961 9 $7,954 $8,159 $5,863 $6,068 $4,387 $5,453 $5,658 $8,569 $8,774 $853 $1,058 10 $8,688 $8,912 $6,405 $6,629 $4,792 $5,957 $6,181 $9,360 $9,584 $931 $1,155 11 $9,422 $9,665 $6,946 $7,189 $5,197 $6,460 $6,703 $10,151 $10,394 $1,009 $1,252 12 $10,156 $10,418 $7,487 $7,749 $5,602 $6,963 $7,225 $10,942 $11,204 $1,087 $1,349 For more than 12, add: $405 for each additional person to increase the FPL. 13 14 15 16 17 18 19 20 $281 $300 $319 $337 $356 $375 $394 $413 HH Size 5% Disregard Amt $734 for each additional person to increase the FPL. $542 for each additional person to increase the FPL. $504 for each additional person to increase the FPL. $791 for each additional person to increase the FPL. $78 for each additional person to increase the FPL. Use the chart below for the correct 5% disregard amount to use for households with more than 12 2021 MAGI INCOME LIMITS EFFECTIVE MARCH 1, 2021 COE-088-Pregnant Women, COE-071 - Infants to Age 1, COE-029 Family COE-072 - Children Age 1 to Age 6 COE-074- Children Age 6 to Age 19 COE-099 - CHIP COE-075 - Low- Income Parents & Caretaker Relatives

Appendix Page A-3-g COE-073- Children Age 6 to 19 HH Size 194% FPL 194% + 5% Disregard 143% FPL 143% + 5% Disregard 107% FPL (no 5% disregard) 133% FPL 133% + 5% Disregard 209% FPL 209% + 5% Disregard State Set Income Limit Limit + 5% Disregard 1 $2,063 $2,116 $1,521 $1,574 $1,138 $1,415 $1,468 $2,223 $2,276 $227 $280 2 $2,788 $2,860 $2,055 $2,127 $1,538 $1,911 $1,983 $3,003 $3,075 $306 $378 3 $3,512 $3,603 $2,589 $2,680 $1,937 $2,408 $2,499 $3,783 $3,874 $384 $475 4 $4,236 $4,345 $3,123 $3,232 $2,337 $2,904 $3,013 $4,564 $4,673 $462 $571 5 $4,960 $5,088 $3,657 $3,785 $2,736 $3,401 $3,529 $5,344 $5,472 $541 $669 6 $5,685 $5,832 $4,190 $4,337 $3,136 $3,897 $4,044 $6,124 $6,271 $619 $766 7 $6,409 $6,574 $4,724 $4,889 $3,535 $4,394 $4,559 $6,904 $7,069 $697 $862 8 $7,133 $7,317 $5,258 $5,442 $3,935 $4,890 $5,074 $7,685 $7,869 $775 $959 9 $7,857 $8,060 $5,792 $5,995 $4,334 $5,387 $5,590 $8,465 $8,668 $853 $1,056 10 $8,582 $8,803 $6,326 $6,547 $4,733 $5,884 $6,105 $9,245 $9,466 $931 $1,152 11 $9,306 $9,546 $6,860 $7,100 $5,133 $6,380 $6,620 $10,026 $10,266 $1,009 $1,249 12 $10,030 $10,289 $7,394 $7,653 $5,532 $6,877 $7,136 $10,806 $11,065 $1,087 $1,346 For more than 12, add: $400 for each additional person to increase the FPL. 13 14 15 16 17 18 19 20 $277 $296 $315 $333 $352 $371 $389 $408 2020 MAGI INCOME LIMITS EFFECTIVE MARCH 1, 2020 $781 for each additional person to increase the FPL. COE-075 - Low-Income Parents & Caretaker Relatives $78 for each additional person to increase the FPL. HH Size 5% Disregard Amt Use the chart below for the correct 5% disregard amount to use for households with more than 12 persons. COE-088-Pregnant Women, COE-071 - Infants to Age 1, COE-029 Family Planning Waiver COE-072 - Children Age 1 to Age 6 COE-074- Children Age 6 to Age 19 COE-099 - CHIP $725 for each additional person to increase the FPL. $534 for each additional person to increase the FPL. $497 for each additional person to increase the FPL.

Appendix Page A-3-f COE-073- Children Age 6 to 19 HH Size 194% FPL 194% + 5% Disregard 143% FPL 143% + 5% Disregard 107% FPL (no 5% disregard) 133% FPL 133% + 5% Disregard 209% FPL 209% + 5% Disregard State Set Income Limit Limit + 5% Disregard 1 $2,020 $2,072 $1,489 $1,541 $1,114 $1,385 $1,437 $2,176 $2,228 $227 $279 2 $2,734 $2,805 $2,016 $2,087 $1,508 $1,875 $1,946 $2,946 $3,017 $306 $377 3 $3,449 $3,538 $2,542 $2,631 $1,902 $2,365 $2,454 $3,715 $3,804 $384 $473 4 $4,163 $4,270 $3,069 $3,176 $2,297 $2,854 $2,961 $4,485 $4,592 $462 $569 5 $4,878 $5,004 $3,596 $3,722 $2,691 $3,344 $3,470 $5,255 $5,381 $541 $667 6 $5,593 $5,737 $4,122 $4,266 $3,085 $3,834 $3,978 $6,025 $6,169 $619 $763 7 $6,307 $6,470 $4,649 $4,812 $3,479 $4,324 $4,487 $6,795 $6,958 $697 $860 8 $7,022 $7,203 $5,176 $5,357 $3,873 $4,814 $4,995 $7,565 $7,746 $775 $956 9 $7,736 $7,935 $5,703 $5,902 $4,267 $5,304 $5,503 $8,334 $8,533 $853 $1,052 10 $8,451 $8,669 $6,229 $6,447 $4,661 $5,794 $6,012 $9,104 $9,322 $931 $1,149 11 $9,165 $9,401 $6,756 $6,992 $5,055 $6,284 $6,520 $9,874 $10,110 $1,009 $1,245 12 $9,880 $10,135 $7,283 $7,538 $5,449 $6,774 $7,029 $10,644 $10,899 $1,087 $1,342 For more than 12, add: $395 for each additional person to increase the FPL. 13 14 15 16 17 18 19 20 $273 $292 $310 $328 $347 $365 $384 $402 HH Size 5% Disregard Amt Use the chart below for the correct 5% disregard amount to use for households with more than 12 persons. COE-088-Pregnant Women, COE-071 - Infants to Age 1, COE-029 Family Planning Waiver COE-072 - Children Age 1 to Age 6 COE-074- Children Age 6 to Age 19 COE-099 - CHIP $715 for each additional person to increase the FPL. $527 for each additional person to increase the FPL. $490 for each additional person to increase the FPL. 2019 MAGI INCOME LIMITS EFFECTIVE MARCH 1, 2019 $770 for each additional person to increase the FPL. COE-075 - Low-Income Parents & Caretaker Relatives For more than 8 persons, add $78 for each additional person to the State Set Income Limit

Appendix Page A-3-e COE-073- Children Age 6 to 19 HH Size 194% FPL 194% + 5% Disregard 143% FPL 143% + 5% Disregard 107% FPL (no 5% disregard) 133% FPL 133% + 5% Disregard 209% FPL 209% + 5% Disregard State Set Income Limit Limit + 5% Disregard 1 $1,963 $2,014 $1,447 $1,498 $1,083 $1,346 $1,397 $2,115 $2,166 $227 $278 2 $2,662 $2,731 $1,962 $2,031 $1,468 $1,825 $1,894 $2,867 $2,936 $306 $375 3 $3,360 $3,447 $2,477 $2,564 $1,853 $2,304 $2,391 $3,620 $3,707 $384 $471 4 $4,058 $4,163 $2,992 $3,097 $2,239 $2,782 $2,887 $4,372 $4,477 $462 $567 5 $4,757 $4,880 $3,506 $3,629 $2,624 $3,261 $3,384 $5,124 $5,247 $541 $664 6 $5,455 $5,596 $4,021 $4,162 $3,009 $3,740 $3,881 $5,877 $6,018 $619 $760 7 $6,154 $6,313 $4,536 $4,695 $3,394 $4,219 $4,378 $6,629 $6,788 $697 $856 8 $6,852 $7,029 $5,051 $5,228 $3,779 $4,698 $4,875 $7,382 $7,559 $775 $952 9 $7,550 $7,745 $5,566 $5,761 $4,165 $5,176 $5,371 $8,134 $8,329 $853 $1,048 10 $8,249 $8,462 $6,080 $6,293 $4,550 $5,655 $5,868 $8,886 $9,099 $931 $1,144 11 $8,947 $9,178 $6,595 $6,826 $4,935 $6,134 $6,365 $9,639 $9,870 $1,009 $1,240 12 $9,646 $9,895 $7,110 $7,359 $5,320 $6,613 $6,862 $10,391 $10,640 $1,087 $1,336 For more than 12, add: $386 for each additional person to increase the FPL. 13 14 15 16 17 18 19 20 $267 $285 $303 $321 $339 $357 $375 $393 HH Size 5% Disregard Amt $699 for each additional person to increase the FPL. $515 for each additional person to increase the FPL. $479 for each additional person to increase the FPL. $753 for each additional person to increase the FPL. For more than 8 persons, add $78 for each additional person to the State Set Income Limit Use the chart below for the correct 5% disregard amount to use for households with more than 12 persons. 2018 MAGI INCOME LIMITS EFFECTIVE MARCH 1, 2018 COE-088-Pregnant Women, COE-071 - Infants to Age 1, COE-029 Family Planning Waiver COE-072 - Children Age 1 to Age 6 COE-074- Children Age 6 to Age 19 COE-099 - CHIP COE-075 - Low-Income Parents & Caretaker Relatives

Appendix Page A-3-d COE-073- Children Age 6 to 19 HH Size 194% FPL 194% + 5% Disregard 143% FPL 143% + 5% Disregard 107% FPL (no 5% disregard) 133% FPL 133% + 5% Disregard 209% FPL 209% + 5% Disregard State Set Income Limit Limit + 5% Disregard 1 $1,950 $2,000 $1,438 $1,488 $1,076 $1,337 $1,387 $2,101 $2,151 $227 $277 2 $2,626 $2,694 $1,936 $2,004 $1,449 $1,800 $1,868 $2,829 $2,897 $306 $374 3 $3,302 $3,387 $2,434 $2,519 $1,821 $2,264 $2,349 $3,557 $3,642 $384 $469 4 $3,977 $4,080 $2,932 $3,035 $2,194 $2,727 $2,830 $4,285 $4,388 $462 $565 5 $4,653 $4,773 $3,430 $3,550 $2,567 $3,190 $3,310 $5,013 $5,133 $541 $661 6 $5,329 $5,466 $3,928 $4,065 $2,939 $3,654 $3,791 $5,741 $5,878 $619 $756 7 $6,005 $6,160 $4,426 $4,581 $3,312 $4,117 $4,272 $6,469 $6,624 $697 $852 8 $6,681 $6,853 $4,924 $5,096 $3,685 $4,580 $4,752 $7,197 $7,369 $775 $947 9 $7,356 $7,546 $5,423 $5,613 $4,058 $5,043 $5,233 $7,925 $8,115 $853 $1,043 10 $8,032 $8,239 $5,921 $6,128 $4,430 $5,507 $5,714 $8,653 $8,860 $931 $1,138 11 $8,708 $8,932 $6,419 $6,643 $4,803 $5,970 $6,194 $9,381 $9,605 $1,009 $1,233 12 $9,384 $9,626 $6,917 $7,159 $5,176 $6,433 $6,675 $10,109 $10,351 $1,087 $1,329 For more than 12, add: $373 for each additional person to increase the FPL. 13 14 15 16 17 18 19 20 $259 $277 $294 $312 $329 $346 $364 $381 HH Size 5% Disregard Amt $676 for each additional person to increase the FPL. $499 for each additional person to increase the FPL. $464 for each additional person to increase the FPL. $729 for each additional person to increase the FPL. For more than 8 persons, add $78 for each additional person to the State Set Income Limit Use the chart below for the correct 5% disregard amount to use for households with more than 12 persons. 2017 MAGI INCOME LIMITS EFFECTIVE MARCH 1, 2017 COE-088-Pregnant Women, COE-071 - Infants to Age 1, COE-029 Family Planning Waiver COE-072 - Children Age 1 to Age 6 COE-074- Children Age 6 to Age 19 COE-099 - CHIP COE-075 - Low-Income Parents & Caretaker Relatives

Appendix Page A-3-c COE-073- Children Age 6 to 19 HH Size 194% FPL 194% + 5% Disregard 143% FPL 143% + 5% Disregard 107% FPL (no 5% disregard) 133% FPL 133% + 5% Disregard 209% FPL 209% + 5% Disregard State Set Income Limit Limit + 5% Disregard 1 $1,921 $1,971 $1,416 $1,466 $1,060 $1,317 $1,367 $2,070 $2,120 $227 $277 2 $2,590 $2,657 $1,910 $1,977 $1,429 $1,776 $1,843 $2,791 $2,858 $306 $373 3 $3,260 $3,344 $2,403 $2,487 $1,798 $2,235 $2,319 $3,512 $3,596 $384 $468 4 $3,929 $4,030 $2,896 $2,997 $2,167 $2,694 $2,795 $4,233 $4,334 $462 $563 5 $4,598 $4,717 $3,390 $3,509 $2,536 $3,153 $3,272 $4,954 $5,073 $541 $660 6 $5,268 $5,404 $3,883 $4,019 $2,906 $3,611 $3,747 $5,675 $5,811 $619 $755 7 $5,939 $6,092 $4,377 $4,530 $3,276 $4,071 $4,224 $6,398 $6,551 $697 $850 8 $6,611 $6,781 $4,873 $5,043 $3,647 $4,532 $4,702 $7,122 $7,292 $775 $945 9 $7,284 $7,472 $5,369 $5,557 $4,017 $4,994 $5,182 $7,847 $8,035 $853 $1,041 10 $7,956 $8,161 $5,865 $6,070 $4,388 $5,455 $5,660 $8,571 $8,776 $931 $1,136 11 $8,629 $8,851 $6,360 $6,582 $4,759 $5,916 $6,138 $9,296 $9,518 $1,009 $1,231 12 $9,301 $9,541 $6,856 $7,096 $5,130 $6,377 $6,617 $10,120 $10,360 $1,087 $1,327 For more than 12, add: $371 for each additional person to increase the FPL. 13 14 15 16 17 18 19 20 $257 $274 $292 $309 $326 $344 $361 $378 HH Size 5% Disregard Amt $673 for each additional person to increase the FPL. $496 for each additional person to increase the FPL. $462 for each additional person to increase the FPL. $725 for each additional person to increase the FPL. For more than 8 persons, add $78 for each additional person to the State Set Income Limit Use the chart below for the correct 5% disregard amount to use for households with more than 12 persons. 2016 MAGI INCOME LIMITS EFFECTIVE MARCH 1, 2016 COE-088-Pregnant Women, COE-071 - Infants to Age 1, COE-029 Family Planning Waiver COE-072 - Children Age 1 to Age 6 COE-074- Children Age 6 to Age 19 COE-099 - CHIP COE-075 - Low-Income Parents & Caretaker Relatives

Appendix Page A-3-b COE-073- Children Age 6 to 19 HH Size 194% FPL 194% + 5% Disregard 143% FPL 143% + 5% Disregard 107% FPL (no 5% disregard) 133% FPL 133% + 5% Disregard 209% FPL 209% + 5% Disregard State Set Income Limit Limit + 5% Disregard 1 $1,903 $1,952 $1,403 $1,452 $1,050 $1,305 $1,354 $2,050 $2,099 $227 $276 2 $2,576 $2,642 $1,899 $1,965 $1,421 $1,766 $1,832 $2,775 $2,841 $306 $372 3 $3,248 $3,332 $2,395 $2,479 $1,792 $2,227 $2,311 $3,500 $3,584 $384 $468 4 $3,921 $4,022 $2,890 $2,991 $2,163 $2,688 $2,789 $4,224 $4,325 $462 $563 5 $4,593 $4,711 $3,386 $3,504 $2,534 $3,149 $3,267 $4,949 $5,067 $541 $659 6 $5,266 $5,402 $3,882 $4,018 $2,905 $3,610 $3,746 $5,673 $5,809 $619 $755 7 $5,939 $6,092 $4,377 $4,530 $3,276 $4,071 $4,224 $6,398 $6,551 $697 $850 8 $6,611 $6,781 $4,873 $5,043 $3,647 $4,532 $4,702 $7,122 $7,292 $775 $945 9 $7,284 $7,472 $5,369 $5,557 $4,017 $4,994 $5,182 $7,847 $8,035 $853 $1,041 10 $7,956 $8,161 $5,865 $6,070 $4,388 $5,455 $5,660 $8,571 $8,776 $931 $1,136 11 $8,629 $8,851 $6,360 $6,582 $4,759 $5,916 $6,138 $9,296 $9,518 $1,009 $1,231 12 $9,301 $9,541 $6,856 $7,096 $5,130 $6,377 $6,617 $10,120 $10,360 $1,087 $1,327 For more than 12, add: $371 for each additional person to increase the FPL. 13 14 15 16 17 18 19 20 $257 $274 $292 $309 $326 $344 $361 $378 HH Size 5% Disregard Amt $673 for each additional person to increase the FPL. $496 for each additional person to increase the FPL. $462 for each additional person to increase the FPL. $725 for each additional person to increase the FPL. For more than 8 persons, add $78 for each additional person to the State Set Income Limit Use the chart below for the correct 5% disregard amount to use for households with more than 12 persons. 2015 MAGI INCOME LIMITS EFFECTIVE MARCH 1, 2015 COE-088-Pregnant Women, COE-071 - Infants to Age 1, COE-029 Family Planning Waiver COE-072 - Children Age 1 to Age 6 COE-074- Children Age 6 to Age 19 COE-099 - CHIP COE-075 - Low-Income Parents & Caretaker Relatives

Appendix Page A-3-a COE-073- Children Age 6 to 19 HH Size 194% FPL 194% + 5% Disregard 143% FPL 143% + 5% Disregard 107% FPL (no 5% disregard) 133% FPL 133% + 5% Disregard 209% FPL 209% + 5% Disregard State Set Income Limit Limit + 5% Disregard 1 $1,888 $1,937 $1,392 $1,441 $1,042 $1,295 $1,344 $2,034 $2,083 $227 $276 2 $2,544 $2,610 $1,875 $1,941 $1,403 $1,744 $1,810 $2,740 $2,806 $306 $372 3 $3,201 $3,284 $2,360 $2,443 $1,766 $2,195 $2,278 $3,449 $3,532 $384 $467 4 $3,857 $3,956 $2,843 $2,942 $2,128 $2,645 $2,744 $4,155 $4,254 $462 $561 5 $4,513 $4,629 $3,327 $3,443 $2,489 $3,094 $3,210 $4,862 $4,978 $541 $657 6 $5,171 $5,304 $3,811 $3,944 $2,852 $3,545 $3,678 $5,570 $5,703 $619 $752 7 $5,826 $5,976 $4,295 $4,445 $3,214 $3,994 $4,144 $6,277 $6,427 $697 $847 8 $6,482 $6,649 $4,778 $4,945 $3,575 $4,444 $4,611 $6,983 $7,150 $775 $942 9 $7,138 $7,322 $5,262 $5,446 $3,937 $4,894 $5,078 $7,690 $7,874 $853 $1,037 10 $7,794 $7,995 $5,746 $5,947 $4,299 $5,344 $5,545 $8,397 $8,598 $931 $1,132 11 $8,451 $8,669 $6,229 $6,447 $4,661 $5,794 $6,012 $9,104 $9,322 $1,009 $1,227 12 $9,107 $9,342 $6,713 $6,948 $5,023 $6,244 $6,479 $9,811 $10,046 $1,087 $1,322 For more than 12, add: $363 for each additional person to increase the FPL. 13 14 15 16 17 18 19 20 $252 $269 $286 $302 $319 $336 $353 $370 * Family Planning Waiver increased to 194% FPL effective 01/01/2015 HH Size 5% Disregard Amt $658 for each additional person to increase the FPL. $485 for each additional person to increase the FPL. $451 for each additional person to increase the FPL. $709 for each additional person to increase the FPL. For more than 8 persons, add $78 for each additional person to the State Set Income Limit Use the chart below for the correct 5% disregard amount to use for households with more than 12 persons. 2014 MAGI INCOME LIMITS EFFECTIVE MARCH 1, 2014 COE-088-Pregnant Women, COE-071 - Infants to Age 1, COE-029 Family Planning Waiver* COE-072 - Children Age 1 to Age 6 COE-074- Children Age 6 to Age 19 COE-099 - CHIP COE-075 - Low-Income Parents & Caretaker Relatives

Appendix A-4- a Certifying Agency Category of Eligibility (COE) Coverage Group Description Mandatory or Optional SSI 001 SSI Individual Mandatory DOM 002 SSI Retro Eligibility Mandatory DHS 003 Adult refugees eligible under Refugee Resettlement Grant (identifiable with a Money Pay Indicator of "0") Mandatory Under the Grant CPS 003 Limited to IV-e foster children up to age 21 (identifiable on MMIS with a Money Pay Indicator of "3") Mandatory Limited to IV-e adoption assistance children up to age 21 (identifiable on MMIS with a Money Pay Indicator of "4") Mandatory SSI 005 SSI Only - Institution Mandatory DHS 007 Protected Foster Care Child to Age 26 Mandatory DOM 010 Nursing Facility - under 300% (SSI FBR) Optional DOM 011 Long Term Hospitalization - under 300% (SSI FBR) Optional DOM 012 Swing-Bed - under 300% (SSI FBR) Optional DOM 013 Nursing Facility - would be SSI if at home Optional DOM 014 Long Term Hospitalization - would be SSI if at home Optional DOM 015 Swing Bed-would be SSI if at home Optional DOM 019 Katie Beckett Program Optional DOM 020 Emergency - SSI limitations case Mandatory DOM 021 Emergency Services for Immigrants Not Otherwise Eligible Mandatory DOM 025 Working Disabled Optional CPS 026 Foster Care Child (non-Ive) (identifiable on MMIS with a Money Pay Indicator of "2") Optional Adoption Assistance (non-IVe) (identifiable on MMIS with a Money Pay Indicator of "5") Optional DOM 027 Uninsured Women with Breast/Cervical Cancer Optional DOM 029 Family Planning 1115 Waiver* Optional DOM 031 Qualified Medicare Beneficiaries (QMB)* Mandatory DOM 035 Qualifed Working Disabled Individual (QWDI)* (pays Medicare Part A) Mandatory DOM 045 Healthier MS 1115 Waiver - Aged & Disabled with no Medicare Optional DOM 051 Specified Low Income Medicare Beneficiares (SLMB)* Mandatory DOM 054 Qualified Individuals (QI)-1* Mandatory DOM 062 HCBS Assisted Living Waiver - 1915 (c) Optional

DOM 063 HCBS Elderly/Disabled Waiver - 1915 (c) Optional DOM 064 HCBS Intellectual Disabilities (ID/DD) Waiver - 1915 (c) Optional DOM 065 HCBS Independent Living Waiver - 1915 (c) Optional DOM 066 HCBS Traumatic Brain Injury Waiver - 1915 (c) Optional Appendix A-4- b Certifying Agency Category of Eligibility (COE) Coverage Group Description Mandatory or Optional DOM 071 Infants to age 1 with income at/below the MAGI-Equivalent (ME) income limit for 185% FPL (ME limit = 194% FPL) Mandatory DOM 072 Children age 1-5 with income at/below the MAGI-Equivalent (ME) income limit for 133% FPL (ME limit = 143% FPL) Mandatory DOM 073 Children age 6-19 with income at/below the MAGI-Equivalent (ME) income limit for 100% FPL (ME limit = 107% FPL) Mandatory DOM 074 Children age 6-19 with income above the MAGI-equivalent income limit for 100% FPL but at/below 133% FPL. Mandatory DOM 075 Parent(s) and needy caretakers of minor children under age 18 Mandatory DOM 088 Preg. Women with income at/below the MAGI-Equivalent income limit for 185% FPL (ME limit = 194% FPL) Mandatory DOM 093 Former SSI Recipients Ineligible due to Cost of Living Increase(s) Mandatory DOM 094 Former SSI Recipient - Disabled Adult Child (DAC) Mandatory DOM 095 Former SSI Recipient - Widow(er) 60+ with no Medicare Mandatory DOM 096 Former SSI Recipient - Widow(er) 50+ with no Medicare Mandatory DOM 099 CHIP children eligible under a separate health plan. Optional * does not receive full benefits

Certifying Agency: SSI = Social Security Administration determines eligibility for SSI (Supplemental Security Income) DOM = Division of Medicaid CPS = Child Protection Services (these COE's may continue to reflect DHS as the certifying agency as this was the state agency with custody prior to creation of CPS) DHS = Department of Human Services Dual Eligibility Indicator (DEI) values (on MMIS) for individuals with both Medicaid & Medicare Q = QMB and/or QMB-dual with income at/below 100% FPL. DOM pays both Medicare Part A & B premiums. S = SLMB and/or SLMB dual with income between 100% - 120% FPL. DOM pays Medicare Part B premiums.

D = Dual eligibility exists but individual has income greater than 120% FPL. DOM pays Medicare Part B U = QI only in COE-054. Income is between 120% - 135% FPL. There is no dual eligibility for QI-1 individuals. DOM pays Medicare Part B premiums. Appendix A-4-c INACTIVE CATEGORIES OF ELIGIBILITY Certifying Agency Category of Eligibility (COE) Coverage Group Description Ending Date of COE SSI 006 Protected SSI Child (last child aged out 01/2014) (Mandatory) 1/31/2014 DOM 028 Demonstration to Maintain Independent Employment HIV Demonstration Project limited to 9 MS delta counties) 1115 waiver. (Optional) 9/30/2007 DOM 041 Poverty Level Aged or Disabled (PLAD) < 100% (Optional) 12/31/2005 DOM 042 Poverty Level Aged or Disabled (PLAD)< 120% (Optional) 12/31/2005 DOM 043 Poverty Level Aged or Disabled (PLAD) < 135% (Optional) 12/31/2005 DOM 046 PLAD Waiver - Cancer (1115 Waiver) (Optional) 12/31/2005 DOM 047 PLAD Waiver - Renal (1115 Waiver) (Optional) 12/31/2005 DOM 048 PLAD Waiver - Transplant (1115 Waiver) Ended (Optional) 12/31/2005 DOM 049 PLAD Waiver - Anti-Psychotic (1115 Waiver) (Optional) 12/31/2005 DOM 057 Qualified Individuals (QI)-2* (Mandatory) 12/31/2002 DOM 061 Hospice (Optional) 4/30/2005 DOM 067 HCBS MYPAC Waiver 1915(c) enrollment ended 09/30/2012 (Optional) 9/30/2014 DOM 085 Medical Assistance Intact Family. Effective 01/01/2014, no new applicants were added to this COE. Adults moved to COE-075 and COE-085 children moved to the appropriate new COE of 071, 072 or 073. New COE created for adults DOM 087 Children up to age 6 under 133% of poverty. Effective 01/01/2014, no new applicants were added to this COE. Children transitioned to COE-072. New COE created DOM 090 1973 Grandfathered Case (Mandatory) No remaining grandfathered cases DOM 091 Children under 19 under 100% of poverty. Effective 01/01/2014, no new applicants were added to this COE. Children transitioned to COE073 or 074, as appropriate. New COE created DOM 092 HR-1 - Hurricane Katrina 1115 Waiver 1/31/2006

APPENDIX A-5 Revised 03-01-2026 MONTHLY COUNTABLE PREMIUM MONTHLY COUNTABLE PREMIUM EARNINGS - INDIVIDUAL PER MONTH EARNINGS - COUPLE PER MONTH Below $1995 $0 Below $2705 $0 $1995-$1999.99 $99 $2705-$2719.99 $135 $2000-$2019.99 $100 $2720-$2739.99 $136 $2020-$2039.99 $101 $2740-$2759.99 $137 $2040-$2059.99 $102 $2760-$2779.99 $138 $2060-$2079.99 $103 $2780-$2799.99 $139 $2080-$2099.99 $104 $2800-$2819.99 $140 $2100-$2119.99 $105 $2820-$2839.99 $141 $2120-$2139.99 $106 $2840-$2859.99 $142 $2140-$2159.99 $107 $2860-$2879.99 $143 $2160-$2179.99 $108 $2880-$2899.99 $144 $2180-$2199.99 $109 $2900-$2919.99 $145 $2200-$2219.99 $110 $2920-$2939.99 $146 $2220-$2239.99 $111 $2940-$2959.99 $147 $2240-$2259.99 $112 $2960-$2979.99 $148 $2260-$2279.99 $113 $2980-$2999.99 $149 $2280-$2299.99 $114 $3000-$3019.99 $150 $2300-$2319.99 $115 $3020-$3039.99 $151 $2320-$2339.99 $116 $3040-$3059.99 $152 $2340-$2359.99 $117 $3060-$3079.99 $153 $2360-$2379.99 $118 $3080-$3099.99 $154 $2380-$2399.99 $119 $3100-$3119.99 $155 $2400-$2419.99 $120 $3120-$3139.99 $156 $2420-$2439.99 $121 $3140-$3159.99 $157 $2440-$2459.99 $122 $3160-$3179.99 $158 $2460-$2479.99 $123 $3180-$3199.99 $159 $2480-$2499.99 $124 $3200-$3219.99 $160 $2500-$2519.99 $125 $3220-$3239.99 $161 $2520-$2539.99 $126 $3240-$3259.99 $162 $2540-$2559.99 $127 $3260-$3279.99 $163 $2560-$2579.99 $128 $3280-$3299.99 $164 $2580-$2599.99 $129 $3300-$3319.99 $165 $2600-$2619.99 $130 $3320-$3339.99 $166 $2620-$2639.99 $131 $3340-$3359.99 $167 $2640-$2659.99 $132 $3360-$3379.99 $168 $2660-$2679.99 $133 $3380-$3399.99 $169 SLIDING SCALE FOR WORKING DISABLED PREMIUMS* ELIGIBILITY POLICY AND PROCEDURES MANUAL

APPENDIX A-5 Revised 03-01-2026 MONTHLY COUNTABLE PREMIUM MONTHLY COUNTABLE PREMIUM EARNINGS - INDIVIDUAL PER MONTH EARNINGS - COUPLE PER MONTH SLIDING SCALE FOR WORKING DISABLED PREMIUMS* ELIGIBILITY POLICY AND PROCEDURES MANUAL $2680-$2699.99 $134 $3400-$3419.99 $170 $2700-$2719.99 $135 $3420-$3439.99 $171 $2720-$2739.99 $136 $3440-$3459.99 $172 $2740-$2759.99 $137 $3460-$3479.99 $173 $2760-$2779.99 $138 $3480-$3499.99 $174 $2780-$2799.99 $139 $3500-$3519.99 $175 $2800-$2819.99 $140 $3520-$3539.99 $176 $2820-$2839.99 $141 $3540-$3559.99 $177 $2840-$2859.99 $142 $3560-$3579.99 $178 $2860-$2879.99 $143 $3580-$3599.99 $179 $2880-$2899.99 $144 $3600-$3619.99 $180 $2900-$2919.99 $145 $3620-$3639.99 $181 $2920-$2939.99 $146 $3640-$3659.99 $182 $2940-$2959.99 $147 $3660-$3679.99 $183 $2960-$2979.99 $148 $3680-$3699.99 $184 $2980-$2999.99 $149 $3700-$3719.99 $185 $3000-$3019.99 $150 $3720-$3739.99 $186 $3020-$3039.99 $151 $3740-$3759.99 $187 $3040-$3059.99 $152 $3760-$3779.99 $188 $3060-$3079.00 $153 $3780-$3799.99 $189 $3080-$3099.99 $154 $3800-$3819.99 $190 $3100-$3119.99 $155 $3820-$3839.99 $191 $3120-$3139.99 $156 $3840-$3859.99 $192 $3140-$3159.99 $157 $3860-$3879.99 $193 $3160-$3179.99 $158 $3880-$3899.99 $194 $3180-$3199.99 $159 $3900-$3919.99 $195 $3200-$3219.99 $160 $3920-$3939.99 $196 $3220-$3239.99 $161 $3940-$3959.99 $197 $3240-$3259.99 $162 $3960-$3979.99 $198 $3260-$3279.99 $163 $3980-$3999.99 $199 $3280-$3299.99 $164 $4000-$4019.99 $200 $3300-$3319.99 $165 $4020-$4039.99 $201 $3320-$3325 $166 $4040-$4059.99 $202 $4060-$4079.99 $203 $4080-$4099.99 $204 $4100-$4119.99 $205 $4120-$4139.99 $206 $4140-$4159.99 $207

APPENDIX A-5 Revised 03-01-2026 MONTHLY COUNTABLE PREMIUM MONTHLY COUNTABLE PREMIUM EARNINGS - INDIVIDUAL PER MONTH EARNINGS - COUPLE PER MONTH SLIDING SCALE FOR WORKING DISABLED PREMIUMS* ELIGIBILITY POLICY AND PROCEDURES MANUAL $4160-$4179.99 $208 $4180-$4199.99 $209 $4200-$4219.99 $210 $4220-$4239.99 $211 $4240-$4259.99 $212 $4260-$4279.99 $213 $4280-$4299.99 $214 $4300-$4319.99 $215 $4320-$4339.99 $216 $4340-$4359.99 $217 $4360-$4379.99 $218 $4380-$4399.99 $219 $4400-$4419.99 $220 $4420-$4439.99 $221 $4440-$4459.99 $222 $4460-$4479.99 $223 $4480-$4499.99 $224 $4500-$4509 $225 Premiums are payable for individuals/couples with countable earned income between 150% - 250% of the poverty level for an individual or couple. The premium is 5% of countable earnings.

Appendix A-6 Page 1 of 2 Revised 10/01/2025 DIVISION OF MEDICAID SPECIAL NEEDS TRUST GUIDELINES Medicaid’s guidelines for payments and distributions from a Special Needs Trust are listed below. Medicaid will use these guidelines in its review of the annual accounting for the trust. The Medicaid eligibility of the beneficiary of the trust may be affected if these guidelines are not followed. 1. Payments for medical expenses that are not paid by Medicaid are allowed to be made from the trust. 2. Gifts must not be made from the trust. 3. Compensation paid to a family member from the trust for services rendered as trustee must be reasonable under the circumstances. 4. Compensation paid to a family member from the trust for services rendered as a caregiver to the beneficiary must be reasonable under the circumstances and not exceed rates charged by agencies in the geographic area for the same or similar services. For a parent, the services must be over and above normal parental responsibilities. 5. Medicaid will allow the purchase of residential real property by the trust if the residence serves as the beneficiary’s place of residence. The trust must be the owner of any real property purchased by the trust. Additions or improvements to existing property owned by another individual will be allowed if made for the benefit of the beneficiary. The trust must have a lien on the property for the cost of the additions or improvements. 6. If the trust beneficiary is an SSI recipient, the payment of ad valorem taxes and/or insurance premiums and payment of utilities will produce In Kind Support and Maintenance (ISM) for the beneficiary that will reduce their SSI benefits and must be reported to Medicaid. 7. Medicaid will allow the purchase of a vehicle by the trust only if it is the only household vehicle or is specially equipped to allow the beneficiary to operate the vehicle or to be transported in the vehicle. If the vehicle will be used for anyone other than the beneficiary, all expenses relating to the vehicle must be prorated between the trust and anyone other than the beneficiary that uses the vehicle. If the vehicle is placed in the name of anyone other than the beneficiary, the trust must have a lien on the vehicle title. 8. Payments for vacations and other non-medical trips for the beneficiary must be reasonable under the circumstances and considering the size of the trust.

Appendix A-6 Page 2 of 2

Revised 10/01/2025

9. Payments for recreational opportunities, family visits, or visits to friends for the beneficiary must be reasonable under the circumstances. Payments for family members to visit the beneficiary may be made if the visit is for the purpose of ensuring the safety and well-being of the beneficiary.

10. Payments for non-medical expenses such as radios, televisions, audio or video equipment, computer equipment or electronic devices and/or equipment must be made for the primary benefit of the beneficiary and reasonable under the circumstances and considering the size of the trust.

11. The pre-need payment of burial expenses, the purchase of pre-need burial contracts or the payment of burial insurance premiums are allowable, but if such arrangements have not been made prior to the passing of the beneficiary, they must not be paid until after reimbursement has been made to Medicaid.

12. Payments for the following items will produce In Kind Support and Maintenance (ISM) for the beneficiary: rent, mortgage payments (including property insurance required by the mortgage holder), real property taxes (less any tax rebate/credit), heating fuel, gas, electricity, water, sewer, garbage removal. ISM is considered income and may affect eligibility for Medicaid-only beneficiaries or reduce SSI benefits.

13. Distributions from the trust directly to the beneficiary or to the beneficiary’s bank account will be considered income to the beneficiary in the month in which the distribution is made. Direct distributions must be reported and may result in loss of coverage for Medicaid-only beneficiaries or reduction and possible loss of SSI benefits.

If there are questions as to whether a proposed expense will be allowed by Medicaid, the Trustee should call Division of Medicaid, Office of Eligibility, at 601-359-6120 to determine Medicaid’s position prior to making payment.

As trustee of the ______________________ Special Needs Trust, I acknowledge receipt of these guidelines. I understand that my failure to follow these guidelines may affect the Medicaid eligibility of the beneficiary of the trust.

__________________________________

(Trustee’s Signature)

__________________________________

(Trustee’s name printed)

__________________________________

(Date signed)

LIFE EXPECTANCY TABLE IN EFFECT APRIL 2012 – OCTOBER 2014

Effective Month: April 2012 Appendix A-7-1

LIFE EXPECTANCY TABLE - MALE SOURCE: SSA ACTUARIAL LIFE TABLE AGE LIFE EXPECTANCY

AGE LIFE EXPECTANCY

AGE LIFE EXPECTANCY 0 75.38 41 36.93 82 6.94 1 74.94 42 36.02 83 6.49 2 73.98 43 35.12 84 6.06 3 73.00 44 34.22 85 5.65 4 72.02 45 33.33 86 5.26 5 71.03 46 32.45 87 4.89 6 70.04 47 31.57 88 4.55 7 69.05 48 30.71 89 4.22 8 68.06 49 29.84 90 3.92 9 67.07 50 28.99 91 3.64 10 66.08 51 28.15 92 3.38 11 65.09 52 27.32 93 3.15 12 64.09 53 26.49 94 2.93 13 63.10 54 25.68 95 2.75 14 62.12 55 24.87 96 2.58 15 61.14 56 24.06 97 2.44 16 60.18 57 23.26 98 2.30 17 59.22 58 22.48 99 2.19 18 58.27 59 21.69 100 2.07 19 57.33 60 20.92 101 1.96 20 56.40 61 20.16 102 1.85 21 55.47 62 19.40 103 1.75 22 54.54 63 18.66 104 1.66 23 53.63 64 17.92 105 1.56 24 52.71 65 17.19 106 1.47 25 51.78 66 16.48 107 1.39 26 50.86 67 15.77 108 1.30 27 49.93 68 15.08 109 1.22 28 49.00 69 14.40 110 1.15 29 48.07 70 13.73 111 1.07 30 47.13 71 13.08 112 1.00 31 46.20 72 12.44 113 0.94 32 45.27 73 11.82 114 0.87 33 44.33 74 11.21 115 0.81 34 43.40 75 10.62 116 0.75 35 42.47 76 10.04 117 0.70 36 41.54 77 9.48 118 0.64 37 40.61 78 8.94 119 0.59 38 39.68 79 8.41

39 38.76 80 7.90

40 37.84 81 7.41

LIFE EXPECTANCY TABLE IN EFFECT APRIL 2012 – OCTOBER 2014

Effective Month: April 2012 Appendix A-7-2

LIFE EXPECTANCY TABLE - FEMALE SOURCE: SSA ACTUARIAL LIFE TABLE AGE LIFE EXPECTANCY

AGE LIFE EXPECTANCY

AGE LIFE EXPECTANCY 0 80.43 41 40.97 82 8.31 1 79.92 42 40.03 83 7.77 2 78.95 43 39.10 84 7.26 3 77.97 44 38.17 85 6.77 4 76.99 45 37.24 86 6.31 5 76.00 46 36.32 87 5.87 6 75.01 47 35.41 88 5.45 7 74.02 48 34.50 89 5.06 8 73.03 49 33.59 90 4.69 9 72.04 50 32.69 91 4.36 10 71.04 51 31.80 92 4.04 11 70.05 52 30.91 93 3.76 12 69.06 53 30.02 94 3.50 13 68.07 54 29.14 95 3.26 14 67.08 55 28.27 96 3.05 15 66.09 56 27.40 97 2.87 16 65.11 57 26.53 98 2.70 17 64.13 58 25.67 99 2.54 18 63.15 59 24.82 100 2.39 19 62.18 60 23.97 101 2.25 20 61.20 61 23.14 102 2.11 21 60.23 62 22.31 103 1.98 22 59.26 63 21.49 104 1.86 23 58.29 64 20.69 105 1.74 24 57.32 65 19.89 106 1.62 25 56.35 66 19.10 107 1.52 26 55.38 67 18.32 108 1.41 27 54.40 68 17.55 109 1.31 28 53.44 69 16.79 110 1.22 29 52.47 70 16.05 111 1.13 30 51.50 71 15.32 112 1.05 31 50.53 72 14.61 113 0.97 32 49.56 73 13.91 114 0.89 33 48.60 74 13.22 115 0.2 34 47.64 75 12.55 116 0.75 35 46.68 76 11.90 117 0.70 36 45.72 77 11.26 118 0.64 37 44.76 78 10.63 119 0.59 38 43.81 79 10.03

39 42.86 80 9.43

40 41.91 81 8.86

LIFE EXPECTANCY TABLE IN EFFECT NOV – DEC 2014

Effective Month: November 2014 Appendix A-7-3

LIFE EXPECTANCY TABLE - MALE SOURCE: SSA ACTUARIAL LIFE TABLE AGE LIFE EXPECTANCY

AGE LIFE EXPECTANCY

AGE LIFE EXPECTANCY 0 75.90 41 37.31 82 7.12 1 75.43 42 36.40 83 6.66 2 74 46 43 35.50 84 6.22 3 73.48 44 34.60 85 5.80 4 72.50 45 33.70 86 5.40 5 71 .51 46 32.82 87 5.02 6 70 53 47 31.94 88 4.66 7 69.54 48 31.06 89 4.33 8 68.55 49 30.20 90 4.02 9 67 55 50 29.35 91 3.73 10 66.56 51 28.50 92 3.46 11 65.57 52 27.66 93 3.22 12 64 57 53 26.84 94 3.00 13 63.58 54 26.02 95 2.81 14 62.60 55 25.21 96 2.64 15 61.62 56 24.41 97 2.49 16 60.64 57 23.61 98 2.36 17 59.68 58 22.82 99 2.24 18 58.72 59 22.04 100 2.12 19 57.77 60 21.27 101 2.01 20 56.83 61 20.50 102 1.90 21 55 89 62 19.74 103 1.80 22 54 .96 63 18.99 104 1.70 23 5l.03 64 18.24 105 1.60 24 53.11 65 17.51 106 1.51 25 52. 18 66 16.79 107 1.42 26 51.25 67 16.08 108 1.34 27 50.32 68 15.39 109 1.26 28 49.39 69 14.70 110 1.18 29 48.45 70 14.03 111 1.11 30 47.52 71 13.37 112 1.03 31 46.59 72 12.72 113 0.97 32 45.65 73 12.09 114 0.90 33 44 .72 74 11.47 115 0.84 34 43.79 75 10.87 116 0.78 35 42.86 76 10.28 117 0.72 36 41.93 77 9.71 118 0.67 37 41.00 78 9.16 119 0.61 38 40.07 79 8.62

39 39.15 80 8.10

40 38.23 81 7.60

LIFE EXPECTANCY TABLE IN EFFECT NOV – DEC 2014

Effective Month: November 2014 Appendix A-7-4

LIFE EXPECTANCY TABLE - FEMALE SOURCE: SSA ACTUARIAL LIFE TABLE AGE LIFE EXPECTANCY

AGE LIFE EXPECTANCY

AGE LIFE EXPECTANCY 0 80.81 41 41.29 82 8.51 1 80.28 42 40.35 83 7.97 2 79 3 1 43 39.42 84 7.45 3 78.32 44 38.49 85 6.95 4 77.34 45 37.56 86 6.48 5 76.35 46 36.64 87 6.03 6 75 36 47 35.73 88 5.61 7 74.37 48 34.82 89 5.22 8 73 38 49 33.92 90 4.85 9 72 39 50 33.02 91 4.50 10 71.39 51 32.13 92 4.19 11 70 40 52 31.24 93 3.89 12 69.41 53 30.36 94 3.63 13 68.41 54 29.48 95 3.39 14 67.42 55 28.60 96 3.18 15 66.44 56 27.73 97 2.98 16 65.45 57 26.87 98 2.81 17 64.47 58 26.00 99 2.65 18 63 49 59 25.15 100 2.49 19 62.51 60 24.30 101 2.35 20 61 53 61 23.46 102 2.21 21 60.56 62 22.63 103 2.07 22 59 .58 63 21.81 104 1.94 23 58.61 64 20.99 105 1.82 24 57.64 65 20.19 106 1.70 25 56.67 66 19.39 107 1.59 26 55.70 67 18.61 108 1.48 27 54.73 68 17.84 109 1.38 28 53 76 69 17.08 110 1.28 29 52.79 70 16.33 111 1.19 30 51.82 71 15.59 112 1.10 31 50 86 72 14.87 113 1.02 32 49.89 73 14.16 114 0.94 33 48 93 74 13.47 115 0.87 34 47.97 75 12.79 116 0.79 35 47. O J 76 12.13 117 0.73 36 46 05 77 11.48 118 0.67 37 45.09 78 10.86 119 0.61 38 44.14 79 10.24

39 43.19 80 9.65

40 42.24 81 9.07

LIFE EXPECTANCY TABLE IN EFFECT JAN 2015 – SEPT 2016

Effective Month: January 2015 Appendix A-7-5

LIFE EXPECTANCY TABLE - MALE SOURCE: SSA ACTUARIAL LIFE TABLE AGE LIFE EXPECTANCY

AGE LIFE EXPECTANCY

AGE LIFE EXPECTANCY 0 76.10 41 37.45 82 7.11 1 75.62 42 36.53 83 6.65 2 74.65 43 35.62 84 6.21 3 73.67 44 34.72 85 5.78 4 72.69 45 33.82 86 5.38 5 71.70 46 32.93 87 5.00 6 70.71 47 32.05 88 4.64 7 69.72 48 31.17 89 4.30 8 68.73 49 30.31 90 3.99 9 67.74 50 29.45 91 3.70 10 66.74 51 28.60 92 3.44 11 65.75 52 27.76 93 3.20 12 64.76 53 26.93 94 2.98 13 63.76 54 26.10 95 2.79 14 62.78 55 25.29 96 2.62 15 61.80 56 24.48 97 2.47 16 60.82 57 23.69 98 2.34 17 59.86 58 22.90 99 2.22 18 58.90 59 22.12 100 2.10 19 57.95 60 21.34 101 1.99 20 57.00 61 20.57 102 1.88 21 56.06 62 19.81 103 1.78 22 55.13 63 19.05 104 1.68 23 54.20 64 18.30 105 1.59 24 53.27 65 17.57 106 1.50 25 52.34 66 16.84 107 1.41 26 51.41 67 16.13 108 1.32 27 50.48 68 15.43 109 1.24 28 49.55 69 14.75 110 1.17 29 48.62 70 14.07 111 1.09 30 47.68 71 13.40 112 1.02 31 46.75 72 12.75 113 0.95 32 45.82 73 12.12 114 0.89 33 44.88 74 11.49 115 0.83 34 43.95 75 10.89 116 0.77 35 43.02 76 10.30 117 0.71 36 42.08 77 9.72 118 0.66 37 41.15 78 9.17 119 0.60 38 40.22 79 8.63

39 39.30 80 8.10

40 38.37 81 7.60

LIFE EXPECTANCY TABLE IN EFFECT JAN 2015 – SEPT 2016

Effective Month: January 2015 Appendix A-7-6

LIFE EXPECTANCY TABLE - FEMALE SOURCE: SSA ACTUARIAL LIFE TABLE AGE LIFE EXPECTANCY

AGE LIFE EXPECTANCY

AGE LIFE EXPECTANCY 0 80.94 41 41.38 82 8.47 1 80.39 42 40.43 83 7.93 2 79.43 43 39.50 84 7.41 3 78.44 44 38.56 85 6.91 4 77.46 45 37.63 86 6.44 5 76.47 46 36.71 87 5.99 6 75.47 47 35.79 88 5.56 7 74.48 48 34.88 89 5.17 8 73.49 49 33.97 90 4.80 9 72.50 50 33.07 91 4.45 10 71.50 51 32.18 92 4.13 11 70.51 52 31.29 93 3.84 12 69.52 53 30.40 94 3.58 13 68.52 54 29.52 95 3.34 14 67.53 55 28.65 96 3.13 15 66.54 56 27.77 97 2.94 16 65.56 57 26.91 98 2.76 17 64.57 58 26.04 99 2.60 18 63.59 59 25.19 100 2.45 19 62.61 60 24.34 101 2.31 20 61.63 61 23.49 102 2.17 21 60.66 62 22.65 103 2.03 22 59.68 63 21.83 104 1.91 23 58.71 64 21.01 105 1.79 24 57.74 65 20.20 106 1.67 25 56.77 66 19.40 107 1.56 26 55.79 67 18.62 108 1.45 27 54.82 68 17.84 109 1.35 28 53.85 69 17.08 110 1.26 29 52.88 70 16.33 111 1.17 30 51.92 71 15.59 112 1.08 31 50.95 72 14.87 113 1.00 32 49.98 73 14.16 114 0.92 33 49.02 74 13.46 115 0.84 34 48.06 75 12.77 116 0.77 35 47.10 76 12.11 117 0.71 36 46.14 77 11.46 118 0.66 37 45.18 78 10.83 119 0.60 38 44.23 79 10.21

39 43.27 80 9.61

40 42.32 81 9.03

LIFE EXPECTANCY TABLE IN EFFECT OCT 2016 – NOV 2017

Effective Month: October 2016 Appendix A-7-7

LIFE EXPECTANCY TABLE - MALE SOURCE: SSA ACTUARIAL LIFE TABLE AGE LIFE EXPECTANCY

AGE LIFE EXPECTANCY

AGE LIFE EXPECTANCY 0 76.28 41 37.61 82 7.19 1 75.78 42 36.70 83 6.72 2 74.82 43 35.78 84 6.27 3 73.84 44 34.88 85 5.84 4 72.85 45 33.98 86 5.43 5 71.87 46 33.08 87 5.04 6 70.88 47 32.19 88 4.68 7 69.89 48 31.32 89 4.34 8 68.90 49 30.44 90 4.03 9 67.90 50 29.58 91 3.74 10 66.91 51 28.73 92 3.47 11 65.92 52 27.89 93 3.23 12 64.92 53 27.05 94 3.01 13 63.93 54 26.23 95 2.82 14 62.94 55 25.41 96 2.64 15 61.96 56 24.61 97 2.49 16 60.99 57 23.82 98 2.36 17 60.02 58 23.03 99 2.24 18 59.05 59 22.25 100 2.12 19 58.09 60 21.48 101 2.01 20 57.14 61 20.72 102 1.90 21 56.20 62 19.97 103 1.80 22 55.27 63 19.22 104 1.70 23 54.33 64 18.48 105 1.60 24 53.40 65 17.75 106 1.51 25 52.47 66 17.03 107 1.42 26 51.54 67 16.32 108 1.34 27 50.61 68 15.61 109 1.26 28 49.68 69 14.92 110 1.18 29 48.75 70 14.24 111 1.11 30 47.82 71 13.57 112 1.04 31 46.89 72 12.92 113 0.97 32 45.96 73 12.27 114 0.90 33 45.03 74 11.65 115 0.84 34 44.10 75 11.03 116 0.78 35 43.17 76 10.43 117 0.72 36 42.24 77 9.85 118 0.67 37 41.31 78 9.28 119 0.61 38 40.38 79 8.73

39 39.46 80 8.20

40 38.53 81 7.68

LIFE EXPECTANCY TABLE IN EFFECT OCT 2016 – NOV 2017

Effective Month: October 2016 Appendix A-7-8

LIFE EXPECTANCY TABLE - FEMALE SOURCE: SSA ACTUARIAL LIFE TABLE AGE LIFE EXPECTANCY

AGE LIFE EXPECTANCY

AGE LIFE EXPECTANCY 0 81.05 41 41.48 82 8.48 1 80.49 42 40.54 83 7.94 2 79.52 43 39.60 84 7.42 3 78.54 44 38.66 85 6.92 4 77.55 45 37.73 86 6.44 5 76.56 46 36.81 87 5.99 6 75.57 47 35.89 88 5.57 7 74.58 48 34.97 89 5.17 8 73.58 49 34.06 90 4.80 9 72.59 50 33.16 91 4.45 10 71.60 51 32.27 92 4.13 11 70.60 52 31.38 93 3.84 12 69.61 53 30.49 94 3.57 13 68.62 54 29.62 95 3.34 14 67.63 55 28.74 96 3.12 15 66.64 56 27.88 97 2.93 16 65.65 57 27.01 98 2.76 17 64.67 58 26.16 99 2.60 18 63.68 59 25.31 100 2.45 19 62.70 60 24.46 101 2.30 20 61.72 61 23.62 102 2.17 21 60.75 62 22.78 103 2.03 22 59.77 63 21.95 104 1.91 23 58.80 64 21.13 105 1.78 24 57.82 65 20.32 106 1.67 25 56.85 66 19.52 107 1.56 26 55.88 67 18.73 108 1.45 27 54.91 68 17.95 109 1.35 28 53.94 69 17.18 110 1.26 29 52.97 70 16.43 111 1.17 30 52.01 71 15.68 112 1.08 31 51.04 72 14.95 113 1.00 32 50.08 73 14.23 114 0.92 33 49.11 74 13.53 115 0.85 34 48.15 75 12.83 116 0.78 35 47.19 76 12.16 117 0.72 36 46.23 77 11.50 118 0.67 37 45.28 78 10.86 119 0.61 38 44.33 79 10.24

39 43.37 80 9.64

40 42.43 81 9.05

LIFE EXPECTANCY TABLE DECEMBER 2017 - CURRENT Effective Month: December 2017

Appendix Page A-7-9 LIFE EXPECTANCY TABLE - MALE SOURCE: SSA ACTUARIAL LIFE TABLE AGE LIFE EXPECTANCY

AGE LIFE EXPECTANCY

AGE LIFE EXPECTANCY 0 76.33 41 37.68 82 7.27 1 75.81 42 36.76 83 6.80 2 74.84 43 35.85 84 6.34 3 73.86 44 34.95 85 5.91 4 72.88 45 34.04 86 5.50 5 71.89 46 33.15 87 5.11 6 70.90 47 32.26 88 4.74 7 69.91 48 31.38 89 4.40 8 68.92 49 30.51 90 4.08 9 67.93 50 29.64 91 3.79 10 66.94 51 28.79 92 3.52 11 65.94 52 27.94 93 3.27 12 64.95 53 27.11 94 3.05 13 63.96 54 26.29 95 2.85 14 62.97 55 25.47 96 2.68 15 61.99 56 24.67 97 2.53 16 61.02 57 23.87 98 2.39 17 60.05 58 23.09 99 2.27 18 59.08 59 22.32 100 2.15 19 58.13 60 21.55 101 2.04 20 57.18 61 20.79 102 1.93 21 56.24 62 20.04 103 1.83 22 55.30 63 19.30 104 1.73 23 54.37 64 18.57 105 1.63 24 53.44 65 17.84 106 1.54 25 52.51 66 17.12 107 1.45 26 51.58 67 16.40 108 1.36 27 50.65 68 15.70 109 1.28 28 49.72 69 15.01 110 1.20 29 48.79 70 14.32 111 1.13 30 47.86 71 13.66 112 1.05 31 46.93 72 13.00 113 0.98 32 46.00 73 12.36 114 0.92 33 45.07 74 11.73 115 0.86 34 44.15 75 11.11 116 0.79 35 43.22 76 10.51 117 0.74 36 42.29 77 9.93 118 0.68 37 41.37 78 9.36 119 0.63 38 40.44 79 8.81

39 39.52 80 8.28

40 38.60 81 7.76

LIFE EXPECTANCY TABLE DECEMBER 2017 - CURRENT Effective Month: December 2017

Appendix Page A-7-10 LIFE EXPECTANCY TABLE - FEMALE SOURCE: SSA ACTUARIAL LIFE TABLE AGE LIFE EXPECTANCY

AGE LIFE EXPECTANCY

AGE LIFE EXPECTANCY 0 81.11 41 41.55 82 8.58 1 80.54 42 40.61 83 8.04 2 79.57 43 39.67 84 7.52 3 78.59 44 38.74 85 7.01 4 77.60 45 37.81 86 6.53 5 76.61 46 36.88 87 6.08 6 75.62 47 35.96 88 5.64 7 74.63 48 35.05 89 5.23 8 73.64 49 34.14 90 4.85 9 72.64 50 33.24 91 4.50 10 71.65 51 32.34 92 4.18 11 70.66 52 31.45 93 3.88 12 69.66 53 30.57 94 3.61 13 68.67 54 29.70 95 3.37 14 67.68 55 28.83 96 3.16 15 66.69 56 27.96 97 2.96 16 65.70 57 27.10 98 2.79 17 64.72 58 26.25 99 2.63 18 63.73 59 25.40 100 2.48 19 62.75 60 24.56 101 2.33 20 61.77 61 23.72 102 2.19 21 60.80 62 22.89 103 2.06 22 59.82 63 22.07 104 1.93 23 58.85 64 21.25 105 1.81 24 57.87 65 20.44 106 1.69 25 56.90 66 19.63 107 1.58 26 55.93 67 18.84 108 1.47 27 54.96 68 18.06 109 1.37 28 53.99 69 17.29 110 1.27 29 53.03 70 16.53 111 1.18 30 52.06 71 15.78 112 1.09 31 51.10 72 15.05 113 1.01 32 50.13 73 14.34 114 0.93 33 49.17 74 13.63 115 0.86 34 48.21 75 12.94 116 0.79 35 47.25 76 12.26 117 0.74 36 46.29 77 11.60 118 0.68 37 45.34 78 10.96 119 0.63 38 44.39 79 10.33

39 43.44 80 9.73

40 42.49 81 9.14

Page 1 of 3

MS DOM LTC Income Trust Document

EP&P/Appendix A-8-1

Revised July 2017 MISSISSIPPI DIVISION OF MEDICAID

LONG-TERM CARE INCOME TRUST

THE ________________________________________ INCOME TRUST

WHEREAS, __________________________, hereinafter referred to as the Settlor, now has a monthly income that exceeds the current Medicaid income limits, and;

WHEREAS, the total monthly income received by Settlor is not sufficient to pay for expenses associated with long-term care services and related services, and;

WHEREAS, Settlor's other assets have been exhausted by Settlor's long-term care expenses, and;

WHEREAS, the principal purpose of this Trust is to receive all income payments due Settlor in excess of the Settlor’s cost of care, including Social Security benefits, retirement benefits, interest, dividends, or other income. The Settlor’s cost of care will be determined by the daily rate that Medicaid pays the nursing facility in which the Settlor resides. If the rate for the facility is less than the Settlor’s income, the excess income will be used to fund the income trust. If the rate for the facility is more than the Settlor’s income, the Settlor’s total income, less authorized deductions, will be paid to the nursing facility. Any income in excess of the Settlor’s cost of care will be retained as part of the Trust. Income cannot exceed the private pay rate for the nursing facility in which the Settlor resides. If total income is determined to be in excess of the private pay rate for a 31-day month for any month, Medicaid eligibility will be denied or terminated for the month(s) under determination. WITNESSETH:

This _________________________Income Trust Agreement is entered into between _____________________, "Settlor", and ______________, "Trustee", who agree as follows: (A) A portion of the Settlor’s income may be protected in the month of entry into long term care. When income protection is applicable, there is no cost of care payable to the nursing facility. However, income above the amount that is $1 less than the Medicaid institutional income limit is payable to the Division of Medicaid within 30-days after receipt of the notice issued by the Division of Medicaid approving eligibility. The approval notice will inform the Trustee of the amount payable.

(B) In all subsequent month(s) or if income protection for the month of entry does not apply, the Trustee shall place all income in excess of the Settlor’s cost of care into the Trust, and the Trustee shall hold such income under the following terms and conditions:

Page 2 of 3

MS DOM LTC Income Trust Document

EP&P/Appendix A-8-1

Revised July 2017

(1) Trustee shall retain the income in excess of the Settlor’s cost of care in the Income Trust Account.

(2) At the time of each review of the Settlor’s Medicaid eligibility (at least annually) while

this trust is in existence, if the Settlor’s income exceeds the cost of care, the Division of

Medicaid will notify the Trustee of the amount that should be accumulated in the trust.

The Trustee will then be requested to make payment of this amount to the Division of

Medicaid up to the total amount expended by the Division of Medicaid on behalf of the

Settlor that has not previously been repaid to Medicaid. Failure to make the requested

payments will result in the loss of Medicaid eligibility for the Settlor.

(3) This trust will terminate upon the death of the Settlor; when the Settlor’s Medicaid

eligibility is terminated; when the Settlor’s income no longer exceeds the current

Medicaid income limits; or when the trust is otherwise terminated. At that time, any

income amounts accumulated in the trust shall be paid over to the Division of Medicaid,

State of Mississippi, up to the total amount expended by the Division of Medicaid on

behalf of the Settlor that has not previously been repaid to Medicaid.

(C) When requested, the Trustee shall furnish to the Division of Medicaid, State of Mississippi, an annual accounting to show all receipts and disbursements of the trust during the prior calendar year.

(D) The Trustee shall maintain the trust funds on deposit in a federally insured banking institution.

(E) No Trustee shall receive a Trustee’s fee for services rendered to the trust, however, reasonable bank charges will be allowed.

(F) The Trustee shall give written notice to the Division of Medicaid, State of Mississippi when the Settlor dies or when the trust is otherwise terminated.

(G) The provisions of this Trust shall be interpreted under the laws of the State of Mississippi.

The effective date of this trust shall be __________________________________. IN WITNESS WHEREOF, this ____________________________ Income Trust Agreement has been executed on this the _____ day of __________, 20___. ___________________________________ Trustee

Page 3 of 3

MS DOM LTC Income Trust Document

EP&P/Appendix A-8-1

Revised July 2017

___________________________________ Settlor STATE OF _________________

COUNTY OF _______________

Personally appeared before me, the undersigned authority in and for said county and state, on the ______ day of ______, 20___, within my jurisdiction, the within named ____________________, who acknowledged that (he) (she) executed the above and foregoing instrument. ___________________________ (NOTARY PUBLIC) MY COMMISSION EXPIRES: STATE OF _________________

COUNTY OF _______________ Personally appeared before me, the undersigned authority in and for said county and state, on the _____day of __________, 20___, within my jurisdiction, the within named ________________, who acknowledged that (he) (she) (they) executed the above and foregoing instrument.

____________________________ (NOTARY PUBLIC)

MY COMMISSION

TRUSTEE INFORMATION:

NAME: ____________________ SSN: ____________________

TELEPHONE NUMBER: ____________________

ADDRESS: ________________________________

________________________________

RELATIONSHIP TO SETTLOR: ____________________

(Rev 6/08)

MISSISSIPPI DIVISION OF MEDICAID LONG TERM CARE INCOME TRUST – HELP SHEET

Long Term Care Income Trust Help Sheet, Revised June 2020 Page 1

The purpose of an Income Trust is to allow an individual with recurring excess monthly income who has exhausted all available resources to become eligible for Medicaid while in a nursing facility. Certain conditions apply which are outlined below. The federal authority for an Income Trust is found in Section 1917 (d) of the Social Security Act (42 U.S.C. §1396 p (d) (4)). Basic Income Trust Rules: 1. A Long Term Care Income Trust is available for someone receiving an institutional level of care in a nursing facility. An Income Trust is not available for someone in an acute care hospital or Psychiatric Residential Care Facility (PRTF).

2. An individual requiring an Income Trust who has a court appointed conservator must furnish a copy of the Chancery Court Order authorizing the conservator to establish the Income Trust. The court must be made aware of the Income Trust requirement to pay the MS Division of Medicaid any accumulated trust funds up to an amount expended by Medicaid under the terms of the Income Trust. Income Trust Requirements – Please read carefully: 3. Income that funds the Income Trust is all income due the individual from all sources such as Social Security, pension benefits, interest income and any/all other types and sources of income.

4. The Income Trust must specify the effective date of the trust. The effective date is the date the individual is determined eligible for Medicaid on all factors which may be up to three (3) months prior to the month of the Medicaid application provided the Income Trust is properly funded. Consultation with the Medicaid Regional Office is needed prior to the execution of the trust to confirm the effective date needed. Medicaid eligibility can begin in a month later than the stated effective date of an Income Trust but Medicaid eligibility cannot begin in any month prior to the stated effective date of an Income Trust. An executed Income Trust without an effective date will begin on the date the trust is signed and dated if the individual is otherwise eligible. It is important that you review #5 below to consider month of entry requirements for the individual’s income.

5. In the month of entry to a nursing facility, income may be protected, which means the individual does not contribute toward the cost of care in the facility for any partial month of entry into the facility from the individual’s home. For an individual eligible for Medicaid under the terms of an Income Trust, income that may be protected in the month of entry is limited to income that is $1 less than the institutional limit in effect at the time of entry into the facility. Income above this amount is payable to the Division of Medicaid within thirty (30) days of the notice issued by the Division of Medicaid approving eligibility for the individual. The approval notice will specify the amount payable for the month of entry. NOTE: The individual has the option to request that Medicaid eligibility be delayed until the month following the month of entry to avoid paying the Division of Medicaid the excess income due in the month of entry. This option may be beneficial to the individual if entry into the facility is at the end of the month.

MISSISSIPPI DIVISION OF MEDICAID LONG TERM CARE INCOME TRUST – HELP SHEET

Long Term Care Income Trust Help Sheet, Revised June 2020 Page 2

Income Trust Requirements (Continued) – Please read carefully: Paying the private pay rate to the facility for a late month admission may be less than the amount payable to Medicaid. If this option is chosen, the individual assumes full financial responsibility for the month of entry.

6. In all subsequent months or if income is not protected for the month of entry, the income that is payable to the nursing facility, referred to as Medicaid Income, and any income that funds the trust must be handled as follows:

• If income of the individual is less than the per diem payment the Division of Medicaid will make to the facility for any month, all income of the individual (less authorized deductions) must be paid directly to the nursing facility as Medicaid Income. This determination is made based on the daily Medicaid rate payable to the facility, which varies depending on the facility and days in the month.

• If income of the individual is more than the per diem payment the Division of Medicaid will make to the facility in any month, the income in excess of the Medicaid payment must fund the trust until such time that payment of the accumulated Income Trust funds is requested by the Division of Medicaid. A bank account that is separate from the account used for the individual’s living expenses must be established for income that must fund the trust. The account does not have to be styled as a trust account; it only has to be a separate account for accumulated funding that will be electronically verified by the Division of Medicaid for compliance with the Income Trust provision. If electronic verification is not possible, the individual must verify the separate account and account balance at the time of application and at each annual review.

• The Trustee will be notified in writing of the amounts payable to the nursing facility and of any amount of income that must fund the Income Trust for each month of Medicaid eligibility under the Income Trust.

7. A letter specifying the payment due from accumulated trust funds will be issued at each review of the individual’s Medicaid eligibility, which is at least annually, while the Income Trust is in existence. Failure by the Trustee to make the payment by the due date specified in the letter will result in the loss of Medicaid eligibility for the individual.

8. When requested, the Trustee must provide an accounting to the Division of Medicaid to show all receipts and disbursements of the Income Trust during the prior calendar year. Any disbursements not approved by the Division of Medicaid or provided for by the Income Trust will result in the loss of Medicaid eligibility for the individual.

MISSISSIPPI DIVISION OF MEDICAID LONG TERM CARE INCOME TRUST – HELP SHEET

Long Term Care Income Trust Help Sheet, Revised June 2020 Page 3

Completing the Income Trust: 9. The Division of Medicaid provides a model Long Term Care Income Trust agreement for individuals in need of an Income Trust. The only change to this legally binding document that is acceptable is to add a successor Trustee or Co-Trustee. Any changes must be approved by the Division of Medicaid prior to execution of the trust. Once approved and accepted by the Division of Medicaid, the document cannot be modified without prior approval by the Division of Medicaid.

10. The individual requesting eligibility under an Income Trust is referred to as the “Settlor” in the Income Trust document. The Trustee is the individual or entity (such as a bank) that manages the trust and has fiduciary responsibilities. The Settlor and Trustee cannot be the same person.

Income Trust Restrictions: 11. A Long Term Care Income Trust is used only for income belonging to the individual. No resources (assets) may be used to establish or augment the Income Trust as this will void the trust exception, resulting in the loss of Medicaid eligibility.

12. No fees are allowed to be paid to the Trustee for their service. In the event funds are retained in the trust, administrative fees are limited to $10 per month are intended to cover any bank charges required to maintain an Income Trust bank account.

13. An Income Trust is not allowed on a temporary or intermittent basis except in instances when recurring excess monthly income that does not exceed the facility’s private pay rate as outlined in #14 below will be reduced at a future date. In such a situation, an Income Trust will be allowed until such time as the excess income is reduced and an Income Trust is no longer required to allow eligibility.

• Income received less often than monthly does not qualify as recurring excess monthly income that allows the use of an Income Trust.

• Irregular or infrequent income must be converted into a monthly income before allowing an Income Trust to be established.

14. If the individual has total income that exceeds the monthly private pay rate for the facility in which he/she resides, Medicaid eligibility will be denied. The Division of Medicaid will use the facility’s daily private pay rate in effect for a 31-day month for the period of time under consideration for Medicaid eligibility to make this determination. If income exceeds the 31-day private pay rate for any month(s) after Medicaid eligibility is approved, Medicaid will be terminated. If eligibility cannot be terminated due to advance notice requirements, but income can be counted for Medicaid Income purposes, the excess income will be payable to the Division of Medicaid upon receipt of notice from the agency.

MISSISSIPPI DIVISION OF MEDICAID LONG TERM CARE INCOME TRUST – HELP SHEET

Long Term Care Income Trust Help Sheet, Revised June 2020 Page 4

Termination of an Income Trust: 15. An Income Trust terminates at the individual’s death, when Medicaid eligibility terminates or when the trust is no longer necessary or the trust is otherwise terminated. The need to terminate an Income Trust prior to the individual’s death may occur in the following situations:

• The individual’s recurring monthly income increases to an amount above the private pay cost for the facility in which the individual resides which results in the disallowance of an Income Trust.

• The individual’s recurring monthly income decreases to an amount below the Medicaid institutional limit, meaning an Income Trust is no longer needed in order for the individual to qualify for Medicaid based on income.

• Medicaid state or federal policy changes regarding how certain income must be counted resulting in the disallowance or the need for an Income Trust.

• The individual is discharged from the nursing facility resulting in the disallowance of a Long Term Care Income Trust in order to qualify for Medicaid

At the time an Income Trust is terminated, all amounts remaining in the Income Trust must be paid to the Division of Medicaid up to an amount equal to the total medical assistance paid by the Division of Medicaid on behalf of the individual that has not previously been paid to the Division of Medicaid. The Trustee will be notified in writing of any remaining trust funds that are due and payable to the Division of Medicaid. An Income Trust is a very simple trust that accomplishes the specific goal of receiving income and disbursing it for the sole purpose of allowing an individual in a nursing facility with income in excess of Medicaid income limits to qualify for Medicaid. It is not intended to be a complex fiduciary trust. For more information, attorneys drafting an Income Trust may contact the Division of Medicaid’s Legal Unit at (601) 359-6050.

Page 1 of 3

MS DOM HCBS Income Trust Document

EP&P/Appendix A-9-1

Revised July 2017

MISSISSIPPI DIVISION OF MEDICAID

HOME AND COMMUNITY BASED SERVICES WAIVER (HCBS) INCOME TRUST

THE ____________________________________ INCOME TRUST

WHEREAS, __________________________, hereinafter referred to as the Settlor, now has a monthly income that exceeds the current Medicaid income limits, and;

WHEREAS, Settlor's other assets have been exhausted by the expenses of the Settlor's care, and;

WHEREAS, the principal purpose of this Trust is to receive all income payments due Settlor, including Social Security benefits, retirement benefits, interest, dividends, or other income, and to allow the Trustee to expend for the benefit of the Settlor each month an amount equal to no more than $1.00 less than the then current Medicaid limit, with any excess income to be retained as a part of the Trust. WITNESSETH:

This _________________________Income Trust Agreement is entered into between _____________________, "Settlor", and ______________, "Trustee", who agree as follows: (A) The Trustee shall place all income due the Settlor into the Trust, and the Trustee shall hold such income under the following terms and conditions:

1) Trustee shall distribute to the Settlor, or for Settlor’s benefit, any amounts allowed by the Division of Medicaid, but the total amount distributed each month shall not exceed an amount equal to $1.00 less than the then current Medicaid income limit.

2) At the time of each review of the Settlor’s Medicaid eligibility (at least annually) while this trust is in existence, the Division of Medicaid will notify the Trustee of the amount that should be accumulated in the trust.

Page 2 of 3

MS DOM HCBS Income Trust Document

EP&P/Appendix A-9-1

Revised July 2017

3) The Trustee will then be requested to make payment of this amount to the Division of Medicaid up to the total amount expended by the Division of Medicaid on behalf of the Settlor that has not previously been repaid to Medicaid. Failure to make the requested payments will result in the loss of Medicaid eligibility for the Settlor.

4) This trust will terminate upon the death of the Settlor; when the Settlor’s Medicaid eligibility is terminated; when the Settlor’s income no longer exceeds the current Medicaid income limits; or when the trust is otherwise terminated. At that time, any income amounts accumulated but undistributed shall be paid over to the Division of Medicaid, State of Mississippi, up to the total amount expended by the Division of Medicaid on behalf of the Settlor that has not previously been repaid to Medicaid.

(B) When requested, the Trustee shall furnish to the Division of Medicaid, State of Mississippi, an annual accounting to show all receipts and disbursements of the trust during the prior calendar year.

(C) The Trustee shall maintain the trust funds on deposit in a federally insured banking institution.

(E) No Trustee shall receive a Trustee’s fee for services rendered to the trust, however, reasonable bank charges will be allowed.

(F) The Trustee shall give written notice to the Division of Medicaid, State of Mississippi when the Settlor dies or when the trust is otherwise terminated.

(F) The provisions of this Trust shall be interpreted under the laws of the State of Mississippi. The effective date of this trust shall be _______________________________. IN WITNESS WHEREOF, this ____________________________ Income Trust Agreement has been executed on this the _____ day of __________, 20___.

___________________________________ Trustee

___________________________________ Settlor

Page 3 of 3

MS DOM HCBS Income Trust Document

EP&P/Appendix A-9-1

Revised July 2017

STATE OF _________________ COUNTY OF _______________ Personally appeared before me, the undersigned authority in and for said county and state, on the ______ day of ______, 20___, within my jurisdiction, the within named ____________________, who acknowledged that (he) (she) executed the above and foregoing instrument. ___________________________ (NOTARY PUBLIC) MY COMMISSION EXPIRES:

STATE OF _________________ COUNTY OF _______________ Personally appeared before me, the undersigned authority in and for said county and state, on the _____day of __________, 20___, within my jurisdiction, the within named ________________, who acknowledged that (he) (she) (they) executed the above and foregoing instrument. ____________________________ (NOTARY PUBLIC) MY COMMISSION EXPIRES:

TRUSTEE INFORMATION: NAME: ____________________ SSN: ____________________ TELEPHONE NUMBER: ____________________ ADDRESS: ________________________________ ________________________________ RELATIONSHIP TO SETTLOR: ____________________

MISSISSIPPI DIVISION OF MEDICAID HOME & COMMUNITY BASED SERVICES WAIVER INCOME TRUST – HELP SHEET HCBS Income Trust Help Sheet, Revised June 2020 Page 1

The purpose of an Income Trust is to allow an individual with recurring excess monthly income who has exhausted all available resources to become eligible for Medicaid while participating in a Home and Community Based Services (HCBS) Waiver program. Certain conditions apply which are outlined below. The federal authority for an Income Trust is found in Section 1917 (d) of the Social Security Act (42 U.S.C. §1396 p (d) (4)). Basic Income Trust Rules: 1. An HCBS Income Trust is available for someone receiving an institutional level of care while living in a private living arrangement that meets the requirements of home and community based settings. The HCBS Income Trust is not permitted unless the individual is enrolled and participating in a HCBS waiver program.

2. An individual requiring an Income Trust who has a court appointed conservator must furnish a copy of the Chancery Court Order authorizing the conservator to establish the Income Trust. The court must be made aware of the Income Trust requirement to pay the MS Division of Medicaid any accumulated trust funds up to an amount expended by Medicaid under the terms of the Income Trust. Income Trust Requirements – Please read carefully: 3. Income that funds the Income Trust is all income due the individual from all sources such as Social Security, pension benefits, interest income and any/all other types and sources of income. The individual’s right to receive income should not be transferred to the Income Trust; instead, the individual must first receive the income and then place it into the HCBS Income Trust.

4. The HCBS Income Trust must specify the effective date of the trust. The effective date is the date the individual is determined eligible for Medicaid on all factors, including the date a waiver slot is available and HCBS services have been approved. Consultation with the Medicaid Regional Office is needed prior to the execution of the trust to confirm the effective date needed. Medicaid eligibility can begin in a month later than the stated effective date of an Income Trust but Medicaid eligibility cannot begin in any month prior to the stated effective date of an Income Trust. An executed Income Trust without an effective date will begin on the date the trust is signed and dated if the individual is otherwise eligible.

5. Funding of the Income Trust begins in the month the Income Trust is effective or the beginning date of Medicaid eligibility, whichever is later.

6. The HCBS Income Trust must distribute to the individual, or for his/her benefit, an amount equal to not more than $1 less than the then current Medicaid institutional income limit. The Income Trust will not specify the amount of the individual’s income to be released as this amount may change each year since the Medicaid institutional income limit is subject to change each year. The Trustee will be notified in writing of the amount of income that must fund the HCBS Income Trust each month in order to meet the terms of the Income Trust.

MISSISSIPPI DIVISION OF MEDICAID HOME & COMMUNITY BASED SERVICES WAIVER INCOME TRUST – HELP SHEET HCBS Income Trust Help Sheet, Revised June 2020 Page 2

Income Trust Requirements (Continued) – Please read carefully:

A bank account that is separate from the account used for the individual’s living expenses must be established for income that must fund the trust. The account does not have to be styled as a trust account; it only has to be a separate account for accumulated funding that will be electronically verified by the Division of Medicaid for compliance with the Income Trust provision. If electronic verification is not possible, the individual must verify the separate account and account balance at the time of application and at each annual review.

7. A letter specifying the payment due from accumulated trust funds will be issued at each review of the individual’s Medicaid eligibility, which is at least annually, while the HCBS Income Trust is in existence. Failure by the Trustee to make the payment by the due date specified in the letter will result in the loss of Medicaid eligibility for the individual.

8. When requested, the Trustee must provide an accounting to the Division of Medicaid to show all receipts and disbursements of the Income Trust during the prior calendar year. Any disbursements not approved by the Division of Medicaid or provided for by the Income Trust will result in the loss of Medicaid eligibility for the individual. Completing the Income Trust: 9. The Division of Medicaid provides a model HCBS Income Trust agreement for individuals in need of an Income Trust. The only change to this legally binding document that is acceptable is to add a successor Trustee or Co-Trustee. Any changes must be approved by the Division of Medicaid prior to execution of the trust. Once approved and accepted by the Division of Medicaid, the document cannot be modified without prior approval by the Division of Medicaid.

10. The individual requesting eligibility under an Income Trust is referred to as the “Settlor” in the Income Trust document. The Trustee is the individual or entity (such as a bank) that manages the trust and has fiduciary responsibilities. The Settlor and Trustee cannot be the same person. Income Trust Restrictions: 11. An HCBS Income Trust is used only for income belonging to the individual. No resources (assets) may be used to establish or augment the Income Trust as this will void the trust exception, resulting in the loss of Medicaid eligibility.

12. No fees are allowed to be paid to the Trustee for their service. In the event funds are retained in the trust, administrative fees are limited to $10 per month are intended to cover any bank charges required to maintain an Income Trust bank account.

MISSISSIPPI DIVISION OF MEDICAID HOME & COMMUNITY BASED SERVICES WAIVER INCOME TRUST – HELP SHEET HCBS Income Trust Help Sheet, Revised June 2020 Page 3

13. An HCBS Income Trust is not allowed on a temporary or intermittent basis except in instances when recurring excess monthly income will be reduced at a future date. In such a situation, an Income Trust will be allowed until such time as the excess income is reduced and an Income Trust is no longer required to allow eligibility.

• Income received less often than monthly does not qualify as recurring excess monthly income that allows the use of an Income Trust.

• Irregular or infrequent income must be converted into a monthly income before allowing an Income Trust to be established.

Termination of an Income Trust: 14. An Income Trust terminates at the individual’s death, when Medicaid eligibility terminates or when the trust is no longer necessary or the trust is otherwise terminated. The need to terminate an Income Trust prior to the individual’s death may occur in the following situations:

• The individual’s recurring monthly income decreases to an amount below the Medicaid institutional income limit, meaning an Income Trust is no longer needed in order for the individual to qualify for Medicaid based on income.

• Medicaid state or federal policy changes regarding how certain income must be counted resulting in the disallowance or the need for an Income Trust.

• The individual is discharged from the HCBS waiver program resulting in the disallowance of an Income Trust in order to qualify for Medicaid.

At the time an Income Trust is terminated, all amounts remaining in the Income Trust must be paid to the Division of Medicaid up to an amount equal to the total medical assistance paid by the Division of Medicaid on behalf of the individual that has not previously been paid to the Division of Medicaid. The Trustee will be notified in writing of any remaining trust funds that are due and payable to the Division of Medicaid.

An Income Trust is a very simple trust that accomplishes the specific goal of receiving income and disbursing it for the sole purpose of allowing an individual in a nursing facility with income in excess of Medicaid income limits to qualify for Medicaid. It is not intended to be a complex fiduciary trust. For more information, attorneys drafting an Income Trust may contact the Division of Medicaid’s Legal Unit at (601) 359-6050.

ELIGIBILITY POLICY AND PROCEDURES MANUAL 01-01-2026 APPENDIX A-10-A TITLE II YEARLY BENEFIT INCREASES Year % Increase Year % Increase 2016 0 2017 0.3 2015 1.7 2018 2.0 2014 1.5 2019 2.8 2013 1.7 2020 1.6 2012 3.6 2021 1.3 2011 0 2022 5.9 2010 0 2023 8.7 2009 5.8 2024 3.2 2008 2.3 2025 2.5 2007 3.3 2026 2.8 2006 4.1 2005 2.7 2004 2.1 2003 1.4 2002 2.6 2001 3.5 2000 2.4 1999 1.3 1998 2.1 1997 2.9 1996 2.6 1995 2.8 1994 2.6 1993 3.0 1992 3.7 1991 5.4 1990 4.7 1989 4.0 1988 4.2 1987 1.3 1986 3.1 1985 3.5 1984 3.5 1983 0 1982 7.4 1981 11.2 1980 14.3 1979 9.9 1978 6.5 1977 5.9 (COL Computation History)

Appendix Page A-11 revised 01/01/2026 STUDENT EARNED INCOME EXCLUSION (SEIE) CHART

The SEIE allows an individual under age 22 and regularly attending school to have earnings up to the monthly maximum, but not more than the annual maximum, excluded as shown below. Refer to 200.05.02 for a complete policy discussion of the SEIE.

For Year Monthly Exclusion Maximum exclusion for calendar year 2026 $2,410 $9,730 2025 $2,350 $9,460 2024 $2,290 $9,230 2023 $2,220 $8,950 2022 $2,040 $8,230 2021 $1,930 $7,770 2020 $1,900 $7,670 2019 $1,870 $7,550 2018 $1,820 $7,350 2017 $1,790 $7,200 2016 $1,780 $7,180 2015 $1,780 $7,180 2014 $1,750 $7,060 2013 $1,730 $6,960 2012 $1,700 $6,840 2011 $1,640 $6,600 2010 $1,640 $6,600 2009 $1,640 $6,600 2008 $1,550 $6,240 2007 $1,510 $6,100 2006 $1,460 $5,910 2005 $1,410 $5,670 2004 $1,370 $5,520 2003 $1,340 $5,410 2002 $1,320 $5,340 2001 $1,290 $5,200 2000 and earlier $ 400 $1,620

The monthly and yearly limits will be adjusted annually based on increases in the cost of living index. Under this calculation, these amounts will never be lower than the previous year’s amounts. However, there may be years when no increases result from the calculation.

O F F I C E O F T H E G O V E R N O R | M I S S I S S I P P I D I V I S I O N O F M E D I C A I D APPA

To:

To Whom It May Concern From: ____________________________________ Regional Medicaid Office Date: Re:

The individual identified above inquired with this office about his/her possible Medicaid eligibility. Based on unverified, self-attested information provided by this individual, he/she would not qualify for Medicaid under any available coverage group.

This is not an official Medicaid decision. In order to receive an official decision to approve or deny Medicaid coverage, this individual must complete and file a full Medicaid application with the MS Division of Medicaid and allow this agency to do a full review of all factors of eligibility.

The Division of Medicaid is providing this information to this individual upon his/her request for an unofficial denial of Medicaid coverage.

APPENDIX PAGE A-12 M E M O

EXAMPLE: DOM-304 NON-MAGI LETTER

Regional Office Name Address City, State, Zip

Phone: (RO Phone) Fax: (RO Fax)

Name of Potential Applicant Mailing Address City, State, Zip

(DATE)

The Mississippi Division of Medicaid received a referral from the Health Insurance Marketplace, telling us that you would like to apply for Medicaid. On the application you submitted to the federal Health Insurance Marketplace, you said one or more of the following:

• You said you want to apply for Medicaid based on a disability. • You said y o u have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.). • You said you live in a medical facility or nursing home.

Please read this letter to see what you need to do and the kind of additional information we will ask for to see if you are eligible for Medicaid.

If you want to apply for Medicaid, we will need other information, such as your income and resources. Resources are things that you own and are available to help meet your needs, such as: money in the bank, property that you own other than your home, stocks, bonds and other types of resources. We will use the information you provide to see if you are eligible for Medicaid.

If you are applying for Medicaid based on a disability, and the Social Security Administration has already determined that you have a disability, we can use the decision they made. If not, we will ask you to tell us about your disability and how it affects what you do every day. We also need you to tell us about your medical history. The Disability Determination Services (DDS) makes disability decisions for the Division of Medicaid. DDS will determine if you meet disability medical requirements.

If you want to continue with an application for Medicaid because you meet one or more of the conditions above, sign this letter and return it to us by mail, in person, fax or e-mail at application@medicaid.ms.gov. You can also call the local regional office at the telephone number listed above or the Office of Eligibility toll-free at 800-421-2408.

Signature Date

APPENDIX PAGE A-13

CASE NAME:___________________________________________ CASE NUMBER:____________________________________ DATE: ___________________________________

ADMINISTRATIVE REVIEW CONTACT DOCUMENTATION Household Changes: ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ Income Changes: ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ Other Changes: ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ TAX FILING /DEPENDENT STATUS: In the first column write the name of each person in the HH and put an “X” for each person’s tax filing status for the current calendar year and/or indicate tax dependent and claiming status.

Name of HH Member Not a tax filer Filing Married Filing Jointly Married Filing Separately Filing Taxes Single Tax Dependent of someone in HH (List Person) Tax Dependent of someone outside the HH (List Person/Relationship)

CASE NAME:___________________________________________ CASE NUMBER:____________________________________ DATE: ___________________________________

Name of HH Member Not a tax filer Filing Married Filing Jointly Married Filing Separately Filing Taxes Single Tax Dependent of someone in HH (List Person) Tax Dependent of someone outside the HH (List Person/Relationship)

EARNED INCOME Name of Person Working Employer Gross Monthly Income

ALL OTHER TYPES OF INCOME-INCLUDING SELF-EMPLOYMENT

Type/Source First name of person who gets the income Gross Monthly Type/Source First name of person who gets the income Gross Monthly

Name of Person Reporting Changes: ____________________________________ Specialist Name: ________________________________________

Appendix A-15 Revised 07/01/2017 RESOURCE ASSESSMENT NOTICE _______________________________________ Institutional Spouse ___________________ _______________________________________ Community Spouse ___________________ _______________________________________ Date _______________________________ Based on your request for an assessment of resources owned by the couple named above, the Division of Medicaid has determined that the institutional spouse:  would be eligible for Medicaid based on resources, see below for details.  would not be eligible for Medicaid based on resources, see below for details. Resources that are countable in determining Medicaid resource eligibility are as follows: Countable Resource Type Owner(s) of Resource Resource Value

Total Countable Resources of the Couple:

$_________________ Community Spouse (CS) Share: based on federal maximum

$ ________________ Institutional Spouse (IS) Share: based on individual limit

$ ________________ Excess Resources that would be available to the IS

$ ________________ This is an assessment only. Transferring ownership of resources between spouses may be required to arrange spousal shares allowed. In order for the Division of Medicaid to provide an official Medicaid eligibility decision, a full Medicaid application must be filed for long term care Medicaid. Medicaid Specialist ____________________________ Phone # __________________________

_______________ REGIONAL OFFICE Appendix A-16-1-RB283 DIVISION OF MEDICAID (DATE) (ADDRESS) (CITY,STATE,ZIP)

ID#: 00000000000000 (NAME) SSN#: 000-00-0000 (ADDRESS) SSI APPLICATION DATE: 00/00/0000 (CITY,STATE,ZIP)

DIVISION OF MEDICAID

NOTICE OF APPROVAL AND RETROACTIVE MEDICAID

The Division of Medicaid has been informed by the Social Security Administration that you are eligible for Supplemental Security Income (SSI). Individuals who are eligible for SSI are also eligible for Medicaid. Your eligibility for Medicaid begins (DATE). You will receive a plastic Medicaid card soon. This card is good for each month you are eligible.

If you have medical bills in the three months prior to your application for SSI, or for the month(s) between your application for SSI and the month your SSI payment began, notify the regional office shown below and show them this letter to verify receipt of SSI/Medicaid. If you are found eligible for Medicaid during any of these months, some or all of your medical bills may be paid.

ADDRESS: REGIONAL OFFICE DIVISION OF MEDICAID (ADDRESS) (CITY,STATE,ZIP)

TELEPHONE: _______________

Your eligibility for Medicaid will continue as long as you remain eligible for SSI. It is important that you notify your local Social Security Office in (LOCATION OF SSA OFFICE) of any change in address or circumstances as soon as possible.

Enclosure: Medicaid Notice of Non-Discrimination

___________ REGIONAL OFFICE Appendix A-16-2-RB284 DIVISION OF MEDICAID (DATE) (ADDRESS) (CITY,STATE,ZIP)

ID#: (NAME) SSN#: 000-00-0000 (ADDRESS) SSI APPLICATION DATE: (DATE) (CITY,STATE,ZIP)

DIVISION OF MEDICAID

NOTICE OF DENIAL AND RETROACTIVE MEDICAID

In Mississippi, individuals who are eligible for Supplemental Security Income (SSI) are automatically eligible for Medicaid. However, the Division of Medicaid has been advised by the Social Security Administration that your application for SSI (SSI APPLICATION DATE) has been denied. Therefore, you are not eligible for Medicaid as a SSI recipient.

If you disagree with the decision on your application for SSI and Medicaid, you should immediately contact your local Social Security Office as directed on the Supplemental Security Income notice of disapproved claim which you recently received. Your local Social Security Office is located in (LOCATION OF SSA OFFICE).

If you have medical bills in one or more of the 3 months before you applied for SSI and you believe you would have been eligible for SSI at the time, you should apply for Medicaid at the Medicaid Regional Office shown at the end of this notice.

Although you are not eligible for Medicaid as a recipient of SSI, you may be eligible for Medicaid under one of the following Medicaid-only groups if you have Medicare or you are disabled. Medicaid disability rules are the same as SSI and Social Security.

1. You have or can get Medicare Part A Hospital Insurance and your income does not exceed the federal poverty level for an individual or couple. There is no resource test for this coverage. Medicaid will pay Medicare cost-sharing expenses under the Qualified Medicare Beneficiary (QMB) group.

2. You have Medicare Part A and your income does not exceed 135% of the federal poverty level for an individual or couple. There is no resource test for this group. Medicaid will pay your Medicare Part B premiums only under either the Specified Low Income Beneficiary (SLMB) or Qualified Individual (QI) groups.

3. You are a disabled child living at home and are age 18 or under and receiving medical care at home that would be provided in a medical institution.

Appendix A-16-2-RB284 Page: 2

4. You are in a nursing home or hospital for 31 consecutive days or longer and your total income is below the Medicaid institutional limit. Your resources must not exceed $4000 for an individual.

5. You once received SSI and were terminated for one of the following reasons but would still be eligible for SSI if we disregard the income that made you ineligible such as:

a. A cost-of-living increase in Social Security.

b. Entitlement to or an increase in Social Security disabled adult child benefits after July 1, 1987.

c. Entitlement to Social Security widow(er) benefits for those between age 50-65 who are not eligible for Medicare.

6. You are disabled and working at least 40 hours per month. Your gross monthly earned income cannot exceed 250% of the federal poverty level for an individual or couple. Your unearned income cannot exceed 135% of the federal poverty level for an individual or couple. Resources cannot exceed $24,000 for an individual and $26,000 for a couple. A monthly premium is payable for an individual or couple whose earnings exceed 150% of the poverty level for Working Disabled coverage.

7. You are disabled and not eligible for Medicare. Your income cannot exceed 135% of the federal poverty level for an individual or couple. Your resources must not exceed $4000 for an individual or $6000 for a couple for coverage in the Healthier Mississippi Waiver program.

8. You are a pregnant woman with household income that does not exceed

194% of the federal poverty limit.

The income limits referred to above can be found on the Division of Medicaid’s website at www.medicaid.ms.gov under “see if you qualify for Mississippi Medicaid health benefits,” or you may call the Regional Office to get income and other information about Medicaid coverage.

If you believe that you are eligible under one of the groups described above, you should contact:

ADDRESS: REGIONAL OFFICE DIVISION OF MEDICAID (ADDRESS) (CITY,STATE,ZIP)

TELEPHONE: _____________

or present this letter of denial to that office. Enclosure: Medicaid Notice of Non-Discrimination

_________________ REGIONAL OFFICE

Appendix A-16-3 – RB285 DIVISION OF MEDICAID

(DATE) (ADDRESS) (CITY, STATE, ZIP)

(NAME)

ID#: 00000000000000000 (ADDRESS)

SSN# 000-00-0000 (CITY,STATE,ZIP) SSI APPLICATION DATE: 00/00/0000

DIVISION OF MEDICAID

NOTICE OF DENIAL OF MEDICAID

In Mississippi, individuals who are eligible for Supplemental Security Income (SSI) are automatically eligible for Medicaid. However, the Division of Medicaid has been advised by the Social Security Administration that you failed to assign your third party medical payments to the Division of Medicaid. As a result, your Medicaid coverage has been denied.

If you disagree with the decision to deny your Medicaid based on the reason cited above, you may notify us immediately in writing to request a hearing in this matter.

Per Federal (P.L. 98-39, Section 2367) and State laws, it is mandatory that you assign your third party medical payments (medical insurance) to the Medicaid agency in order to be eligible for Medicaid benefits.

Send your request for a hearing to:

Office of Eligibility

Mississippi Division of Medicaid

550 High Street

Suite 1000

Jackson, MS 39201-1399

Enclosure: Medicaid Notice of Non-Discrimination

___________ REGIONAL OFFICE Appendix A-16-4-RB286 DIVISION OF MEDICAID (DATE) (ADDRESS) (CITY,STATE,ZIP)

(NAME) ID#: 0000000000000 (ADDRESS)

SSN#: 000-00-0000

(CITY,STATE,ZIP)

SSI APPLICATION DATE: (DATE)

DIVISION OF MEDICAID

NOTICE OF TERMINATION OF MEDICAID

The Division of Medicaid has been notified by the Social Security Administration that your Supplemental Security Income (SSI) payment has been terminated or suspended. Since the receipt of SSI was the basis of your entitlement to Medicaid, your Medicaid benefits will be terminated effective (DATE).

If you disagree with the decision made to terminate your SSI check and Medicaid, you should immediately contact your local Social Security Office in (LOCATION OF SSA OFFICE)as directed in the Supplemental Security Income notice of change which you recently received.

Although you are no longer eligible for Medicaid as a recipient of SSI, you may continue to be eligible for Medicaid under one of the following groups if you have Medicare or you are disabled. Medicaid disability rules are the same as SSI and Social Security.

1. You have or can get Medicare Part A Hospital Insurance and your income does not exceed the federal poverty level for an individual or couple. There is no resource test for this coverage. Medicaid will pay Medicare cost-sharing expenses under the Qualified Medicare Beneficiary (QMB) group.

2. You have Medicare Part A and your income does not exceed 135% of the federal poverty level for an individual or couple. There is no resource test for this group. Medicaid will pay your Medicare Part B premiums only under either the Specified Low Income Beneficiary (SLMB) or Qualified Individual (QI)groups.

3. You are a disabled child living at home and are age 18 or under and receiving medical care at home that would ordinarily be provided in a medical institution.

Appendix A-16-4-RB286

Page: 2

4. You are in a nursing home or hospital for 31 consecutive days or longer and your total income is below the Medicaid institutional limit. Your resources must not exceed $4000 for an individual.

5. You once received SSI and were terminated for one of the following reasons but would still be eligible for SSI if we disregard the income that made you ineligible such as:

a. A cost-of-living increase in Social Security.

b. Entitlement to or an increase in Social Security disabled adult child benefits after July 1, 1987.

c. Entitlement to Social Security widow(er) benefits for those between age 50-65 who are not eligible for Medicare.

6. You are disabled and working at least 40 hours per month. Your gross monthly earned income cannot exceed 250% of the federal poverty level for an individual or couple. Your unearned income cannot exceed 135% of the federal poverty level for an individual or couple. Resources cannot exceed $24,000 for an individual and $26,000 for a couple. A monthly premium is payable for an individual or couple whose earnings exceed 150% of the poverty level for Working Disabled coverage.

7. You are disabled and not eligible for Medicare. Your income cannot exceed 135% of the federal poverty level for an individual or couple. Your resources must not exceed $4000 for an individual or $6000 for a couple for coverage in the Healthier Mississippi Waiver program.

8. You are a pregnant woman with household income that does not exceed 194% of the federal poverty limit.

The income limits referred to above can be found on the Division of Medicaid’s website at www.medicaid.ms.gov under “see if you qualify for Mississippi Medicaid health benefits,” or you may call the Regional Office to get income and other information about Medicaid coverage.

If you believe that you are eligible under one of the groups described above, you should contact:

ADDRESS: REGIONAL OFFICE DIVISION OF MEDICAID (ADDRESS) (CITY,STATE,ZIP)

TELEPHONE: __________________ within thirty (30) days for a redetermination of your eligibility. Enclosure: Medicaid Notice of Non-Discrimination

_____________ REGIONAL OFFICE Appendix A-16-5-RB287 DIVISION OF MEDICAID

(DATE) (ADDRESS) (CITY,STATE,ZIP)

(NAME) (ADDRESS)

ID#: 000000000000000 (CITY,STATE,ZIP)

SSN: 000-00-0000

DIVISION OF MEDICAID

NOTICE OF TERMINATION OF MEDICAID

The Mississippi Division of Medicaid has been notified by the Social Security Administration that you failed to cooperate in assigning your third party medical payments to the Division of Medicaid. As a result, your Medicaid benefits will be terminated effective (DATE).

If you disagree with the decision made to terminate your Medicaid based on the reason cited above, you may notify us in writing to request a hearing in this matter. We must be notified within ten (10) days of the date of this notice in order for your Medicaid benefits to continue through the hearing process.

Per Federal (P.L. 98-39, Section 2367) and State laws, it is mandatory that you assign your third party medical payments (medical insurance) to the Medicaid agency in order to remain eligible for Medicaid benefits.

Send your written request for a hearing to:

Office of Eligibility

Division of Medicaid

550 High Street

Suite 1000

Jackson, MS 39201-1399

Enclosure: Medicaid Notice of Non-Discrimination

_________________ REGIONAL OFFICE Appendix A-16-6-RB 291 DIVISION OF MEDICAID (DATE) (ADDRESS) (CITY,STATE,ZIP)

ID#: 0000000000000 (NAME) SSN#: 000-00-0000 (ADDRESS) SSI APPLICATION DATE: 00/00/0000 (CITY,STATE,ZIP)

DIVISION OF MEDICAID

NOTICE OF APPROVAL OF RETROACTIVE SSI-RELATED MEDICAID

The Division of Medicaid has been informed by the Social Security Administration that you were eligible for Supplemental Security Income (SSI) in the past. Individuals who are eligible for SSI are also eligible for Medicaid. Your eligibility for SSI Medicaid begins (DATE) and ends (DATE). You will not receive a Medicaid card for this prior period so you will need to show this notice to any providers of medical services, such as doctors or hospitals, if you have medical bills from this period of time. Your Medicaid ID# for this period is shown above.

If you have medical bills in the three months prior to your application for SSI, notify the regional office shown below and show them this letter to verify receipt of medical assistance. If you are found eligible for medical assistance during any of those three months, some or all of your medical bills may be paid.

ADDRESS: _________REGIONAL OFFICE DIVISION OF MEDICAID (ADDRESS) (CITY,STATE,ZIP)

TELEPHONE: __________________

Although you are no longer eligible for Medicaid as a recipient of SSI, you may continue to be eligible for Medicaid under one of the following groups if you have Medicare or you are disabled. Medicaid disability rules are the same as SSI and Social Security.

1. You have or can get Medicare Part A Hospital Insurance and your income does not exceed the federal poverty level for an individual or couple. There is no resource test for this coverage. Medicaid will pay Medicare cost-sharing expenses under the Qualified Medicare Beneficiary (QMB) group.

2. You have Medicare Part A and your income does not exceed 135% of the federal poverty level for an individual or couple. There is no resource test for this group. Medicaid will pay your Medicare Part B premiums only under either the Specified Low Income Beneficiary (SLMB) or Qualified Individual (QI) groups.

Appendix A-16-6-RB 291

PAGE 2

3. You are a disabled child living at-home and are age 18 or under and

receiving medical care at home that would be provided in a medical

institution.

4. You are in a nursing home or hospital for 31 consecutive days or longer

and your total income is below the Medicaid institutional limit. Your

resources must not exceed $4000 for an individual.

5. You once received SSI and were terminated for one of the following

reasons but would still be eligible for SSI if we disregard the income

that made you ineligible such as:

a. A cost-of-living increase in Social Security.

b. Entitlement to or an increase in Social Security disabled adult child benefits after July 1, 1987.

c. Entitlement to Social Security widow(er) benefits for those

between age 50-65 who are not eligible for Medicare.

6. You are disabled and working at least 40 hours per month. Your gross monthly earned income cannot exceed 250% of the federal poverty level for an individual or couple. Your unearned income cannot exceed 135% of the federal poverty level for an individual or couple. Resources cannot exceed $24,000 for an individual and $26,000 for a couple. A monthly premium is payable for an individual or couple whose earnings exceed 150% of the poverty level for Working Disabled coverage.

7. You are disabled and not eligible for Medicare. Your income cannot exceed 135% of the federal poverty level for an individual or couple. Your resources must not exceed $4000 for an individual or $6000 for a couple for coverage in the Healthier Mississippi Waiver program.

8. You are a pregnant woman with household income that does not exceed 194%

of the federal poverty limit.

The income limits referred to above can be found on the Division of Medicaid’s website at www.medicaid.ms.gov under “see if you qualify for Mississippi Medicaid health benefits,” or you may call the Regional Office to get income and other information about Medicaid coverage.

If you believe that you may be eligible under one of the groups described above, you should contact:

ADDRESS: _________REGIONAL OFFICE DIVISION OF MEDICAID (ADDRESS) (CITY,STATE,ZIP)

TELEPHONE: _________________

within thirty (30) days for a redetermination of eligibility.

Enclosure: Medicaid Notice of Non-Discrimination

_________ REGIONAL OFFICE Appendix A-16-7-RB293 DIVISION OF MEDICAID (DATE) (ADDRESS) (CITY,STATE,ZIP)

D#: 00000000000000 (NAME) SSN#: 000-00-0000 (ADDRESS) (CITY,STATE,ZIP)

DIVISION OF MEDICAID

NOTICE OF TERMINATION OF MEDICAID

The Division of Medicaid has been notified by the Social Security Administration that your Supplemental Security Income (SSI) payment has been terminated or suspended. Since the receipt of SSI was the basis of your entitlement to Medicaid, your Medicaid benefits will be terminated effective (DATE).

If you disagree with the decision made to terminate your SSI check and Medicaid, you should immediately contact your local Social Security Office in (LOCATION OF SSA OFFICE)as directed in the Supplemental Security Income notice of change which you recently received.

Although you are no longer eligible for Medicaid as a recipient of SSI, you may continue to be eligible for Medicaid under one of the following groups if you have Medicare or you are disabled. Medicaid disability rules are the same as SSI and Social Security.

1. You have or can get Medicare Part A Hospital Insurance and your income does not exceed the federal poverty level for an individual or couple. There is no resource test for this coverage. Medicaid will pay Medicare cost-sharing expenses under the Qualified Medicare Beneficiary (QMB) group.

2. You have Medicare Part A and your income does not exceed 135% of the federal poverty level for an individual or couple. There is no resource test for this group. Medicaid will pay your Medicare Part B premiums only under either the Specified Low Income Beneficiary (SLMB) or Qualified Individual (QI) groups.

3. You are a disabled child living at home and are age 18 or under and receiving medical care at home that would be provided in a medical institution.

4. You are in a nursing home or hospital for 31 consecutive days or longer and your total income is below the Medicaid institutional limit. Your resources must not exceed $4000 for an individual.

Appendix A-16-7-RB293

PAGE: 2

5. You once received SSI and were terminated for one of the following reasons but would still be eligible for SSI if we disregard the income that made you ineligible such as:

a. A cost-of-living increase in Social Security.

b. Entitlement to or an increase in Social Security disabled

adult child benefits after July 1, 1987.

c. Entitlement to Social Security widow(er) benefits for those

between age 50-65 who are not eligible for Medicare.

6. You are disabled and working at least 40 hours per month. Your

gross monthly income cannot exceed 250% of the federal poverty level

for an individual or couple. Your unearned income cannot exceed 135%

of the federal poverty level for an individual or couple. Resources

cannot exceed $24,000 for an individual and $26,000 for a couple. A

monthly premium is payable for an individual or couple whose

earnings exceed 150% of the poverty level for Working Disabled

coverage.

7. You are disabled and not eligible for Medicare. Your income cannot

exceed 135% of the federal poverty level for an individual or

couple. Your resources must not exceed $4000 for an individual or

$6000 for a couple for coverage in the Healthier MS Waiver program.

8. You are a pregnant woman with household income that does not exceed

194% of the federal poverty limit.

The income limits referred to above can be found on the Division of

Medicaid’s website at www.medicaid.ms.gov under “see if you qualify for

Mississippi Medicaid health benefits,” or you may call the Regional Office

to get income and other information about Medicaid coverage.

If you believe that you may be eligible under one of the groups described

above, you should contact:

ADDRESS: REGIONAL OFFICE DIVISION OF MEDICAID (ADDRESS) (CITY,STATE,ZIP)

TELEPHONE: _______________________

within ten (10)days for a redetermination of your eligibility.

FOR AGED AND DISABLED ONLY

If you believe that you would continue to be eligible for Medicaid under one of the Medicaid groups described above, complete the attached SSI Review Form and take or mail it in to the Medicaid Regional Office shown above within 10 days.

Enclosure: Medicaid Notice of Non-Discrimination

SSI Review Form

Appendix A-17-3 Revised January 2026 SPOUSAL RESOURCE and INCOME RULES

The following Medicaid rules apply to a legally married couple when:

• One spouse enters a nursing facility or hospital for 31 days or longer or enrolls in a Home & Community Based Waiver (referred to as the Institutional Spouse or IS), and

• The other spouse remains in the community and lives at home or with others or in a retirement community (referred to as the Community Spouse or CS).

For these rules to apply, an application for Medicaid must be filed and:

• The IS must have entered a nursing facility or hospital, or • The IS and CS must live together in the same household if the IS applies for a Home & Community Based Waiver program. Resource Rules

The value of all countable resources belonging to the IS and the CS must be determined.

This includes countable resources owned jointly or individually by the couple or their fair share of any resources owned with other persons. The equity value of a resource counts, i.e., the current market value of a resource less any legal debts owed.

Once the equity value of each countable resource is verified, the total value of spousal resources is determined and compared to the following limits:

• The IS resource limit is $4,000, and • The CS resource limit is $162,660 for calendar year 2026. Any amount over the combined total of these 2 limits is considered to be available to the IS, meaning the IS cannot be eligible until excess resources are spent.

If the CS also plans to apply for Medicaid, the CS resource limit may not apply. The CS must be below the resource limit that applies to the at-home Medicaid coverage group

Electronic Verification of Financial Accounts

When you sign the application for Medicaid, you give the Division of Medicaid consent to verify funds held in a financial institution, such as banks and credit unions, through electronic matching of Social Security Numbers belonging to both the IS and CS. Account balances, including balances during the 5-years prior to applying for Medicaid, are used to determine if any accounts have been given away and are used to determine current eligibility for the IS. There are instances that

Appendix A-17-3 Revised January 2026 Page 2 of 3

require that we ask you or your representative to provide verification of bank account activity, such as: • When accounts are discovered that you did not declare on your application or interview, • When accounts are discovered that belong, in part or in full, to the CS (that do not have the name of the IS on the account), • When account balances result in ineligibility for the IS, and • When account information is inconsistent with what you declared on the application. Countable resources do not include:

 The equity value of the home does not count (unless the equity is more than $752,000);  Certain income-producing property does not count if it produces at least 6% of the equity value (this does not include annuities or promissory notes which are evaluated differently);  1 automobile is not counted;  Personal property is not counted up to a $5,000 limit;  The cash value of whole life insurance policies do not count if the face values of all policies on an insured totals $10,000 or less. Term life insurance does not count;  Money set aside for burial up to $6,000 does not count. 90-Day Period to Transfer Resources to the CS

When the IS’ resources exceed $4,000, but the total countable resources for the couple are below the combined limits, a 90-day transfer period is allowed to transfer ownership of resources into the CS’ name with the following results:

• The IS has ownership of resources under the $4,000 limit and • The CS has ownership of resources that will total less than the CS limit shown above. If the IS meets all other Medicaid qualifications, Medicaid eligibility can be approved prior to or during the 90-day period. The 90-days begins with the date the Medicaid Specialist informs the CS in writing of the resource transfers that must take place to arrange resource ownership according to spousal rules. Exception: Transfers to the Community Spouse must take place prior to approving a long term hospital admission.

Options to Reduce Excess Resources

If total resources are above the limits allowed for an IS and CS, the CS can spend-down the excess to allow the IS to qualify for Medicaid. Allowable options include:

• Pay for burial expenses (purchase a pre-paid burial arrangement or add money to an existing arrangement if it is not enough to pay for final expenses),

Appendix A-17-3 Revised January 2026 Page 3 of 3

• Pay household bills such as credit card debt or other outstanding loans with a balance owned, • Purchase items that are needed by the IS or CS, • Purchase investments that will produce income for the CS, • Pay for the cost of care in the nursing facility. The only requirement for spending down excess resources is that the funds are used for the benefit of the Institutional Spouse and/or Community Spouse or a minor or disabled child of the IS or CS.

Income Rules

When an IS qualifies for Medicaid in a nursing facility, income belonging to the IS is available to pay toward the cost of his/her care in the facility. This is referred to as Medicaid Income.

Medicaid Income is not payable for a long term hospital admission or HCBS waiver program or during the time Medicare pays for the cost of the nursing facility room and board.

The CS may qualify for all or a portion of the income of the IS, depending on the actual income of both the IS and CS. Income belonging to the CS is compared to a maximum limit of $4066.50. If the total income of the CS is less than this maximum, the CS may qualify for a spousal allocation of the CS’ income.

For example: the IS has income of $1,000 in Social Security. The CS has income of $500 in Social Security. The CS’ income of $500 when compared to the maximum leaves a deficit well over $1,000. This means the CS will qualify to receive all of the income belonging to the IS and there is no Medicaid Income to pay the nursing facility.

NOTE: If the CS is eligible for Medicaid or wants to apply for Medicaid while living in the community, it is possible to adjust the amount of the spousal allocation so the amount received from the IS will not result in the loss of Medicaid for the Community Spouse.

Spousal resource and income rules no longer apply when any of the following occurs:

• The death of the IS or CS, • The divorce of the IS/CS, • The IS is discharged from the nursing home, hospital or HCBS waiver program, or • The CS enters a nursing facility.

Appendix Page A-18-1 Life Estate and Remainder Interest Tables Citations: 26 CFR 20.2031-7

UNISEX LIFE ESTATE OR REMAINDER TABLE AGE LIFE ESTATE REMAINDER 0 .97188 .02812 1 .98988 .01012 2 .99017 .00983 3 .99008 .00992 4 .98981 .01019 5 .98938 .01062 6 .98884 .01116 7 .98822 .01178 8 .98748 .01252 9 .98663 .01337 10 .98565 .01435 11 .98453 .01547 12 .98329 .01671 13 .98198 .01802 14 .98066 .01934 15 .97937 .02063 16 .97815 .02185 17 .97700 .02300 18 .97590 .02410 19 .97480 .02520 20 .97365 .02635 21 .97245 .02755 22 .97120 .02880 23 .96986 .03014 24 .96841 .03159 AGE LIFE ESTATE REMAINDER 25 .96678 .03322 26 .96495 .03505 27 .96290 .03710 28 .96062 .03938 29 .95813 .04187 30 .95543 .04457 31 .95254 .04746 32 .94942 .05058 33 .94608 .05392 34 .94250 .05750 35 .93868 .06132 36 .93460 .06540 37 .93026 .06974 38 .92567 .07433 39 .92083 .07917 40 .91571 .08429 41 .91030 .08970 42 .90457 .09543 43 .89855 .10145 44 .89221 .10779 45 .88558 .11442 46 .87863 .12137 47 .87137 .12863 48 .86374 .13626 49 .85578 .14422

Appendix Page A-18-2 AGE LIFE ESTATE REMAINDER 50 .84743 .15257 51 .83674 .16126 52 .82969 .17031 53 .82028 .17972 54 .81054 .18946 55 .80046 .19954 56 .79006 .20994 57 .77931 .22069 58 .76822 .23178 59 .75675 .24325 60 .74491 .25509 61 .73267 .26733 62 .72002 .27998 63 .70696 .29304 64 .69352 .30648 65 .67970 .32030 66 .66551 .33449 67 .65098 .34902 68 .63610 .36390 69 .62086 .37914 70 .60522 .39478 71 .58914 .41086 72 .57261 .42739 73 .55571 .44429 74 .53862 .46138 75 .52149 .47851 76 .50441 .49559 77 .48742 .51258 78 .47049 .52951 79 .45357 .54643 80 .43659 .56341 AGE LIFE ESTATE REMAINDER 81 .41967 .58033 82 .40295 .59705 83 .38642 .61358 84 .36998 .63002 85 .35359 .64641 86 .33764 .66236 87 .32262 .67738 88 .30859 .69141 89 .29526 .70474 90 .28221 .71779 91 .26955 .73045 92 .25771 .74229 93 .24692 .75308 94 .23728 .76272 95 .22887 .77113 96 .22181 .77819 97 .21550 .78450 98 .21000 .79000 99 .20486 .79514 100 .19975 .80025 101 .19532 .80468 102 .19054 .80946 103 .18437 .81563 104 .17856 .82144 105 .16962 .83038 106 .15488 .84512 107 .13409 .86591 108 .10068 .89932 109 .04545 .95455

MEDICAID ELIGIBILITY MANUAL Revised 1/1/2026 APPENDIX A-19-1

REQUIRED TO FILE WORKSHEET (Source: 2025 IRS Publication 501, Table 2)

Determine Required to File status of a dependent whose gross income is earned income only or unearned income using the amount listed in the table below for each income type applicable to the individual. Marital Status Condition EARNED Income only UNEARNED Income Only Annual Income Limit Annual Income Limit Single Under 65 and not blind $15,750 $1,350 Single Either 65 or older or blind $17,750 $3,350 Single 65 or older and blind $19,750 $5,350 Married Under 65 and not blind $15,750 $1,350 Married Either 65 or older or blind $17,350 $2,950 Married 65 or older and blind $18,950 $4,550

Use Table Below for Individuals with Both Earned and Unearned Income Annual Income Limits Use this worksheet when a dependent has both earned and unearned income. A dependent is generally Required to File if the dependent's gross income is more than line 5. The following worksheet is pre-filled for a single individual under age 65 and not blind. If other conditions exist, the minimum and maximum amounts will change. If only one type of income is received compare gross to the chart above. 1. Enter dependent's earned income plus $450 2. Minimum amount 1,350 3. Compare lines 1 and 2. Enter the larger amount 4. Maximum amount 15,750 5. Compare lines 3 and 4. Enter the smaller amount 6. Enter the dependent's gross income. If line 6 is more than line 5, the dependent is Required to File an income tax return. (Examples on page A -19-2)

MEDICAID ELIGIBILITY MANUAL Revised 1/1/2026 APPENDIX A-19-2

Required to File Examples Earned Income Only - William is 16. His mother claims him as a tax dependent. He worked part time and earned $1,325 per month/ $15,900 annually. Compared to the chart for earned income only, his gross annual income is more than $15,750. William is required to file. His income counts in the Medicaid budget.

Earned Income Only - Billy is 15. His mother claims him as a dependent. He worked part-time and earned $1,000 per month/$12,000 annually. Compared to the chart for earned income only, his gross annual income is less than $15,750. Billy is not required to file. His income is not used in the Medicaid budget.

Unearned Income Only - Sarah is 18 and single. Her parents claim her as a dependent. She received taxable interest and dividend income of $165 per month/$1,980 annually. Compared to the chart for unearned income only, her gross annual income is more than $1,350. She is required to file a tax return. Her income counts in the Medicaid budget.

Combined Earned and Unearned Income Part 1: Joe is 20, single, not blind, and a full-time college student. He does not provide more than half of his own support. His parents claim him as a dependent. He received $200 taxable interest income and earned $247.50 per month/$2,750 annually from a part-time job. His gross income of $2,950 ($200 interest plus $2,750 in wages) is not more than $3,200, the amount on line 5 of “Required to File” worksheet. Joe is not required to file. His income does not count in the Medicaid budget. See Computation 1 below. Part 2: Same situation as above except Joe had $600 taxable interest income. His gross income of $3,350 ($600 interest plus $2,750 wages) is more than $3,200, which is the total of his wages plus $450 and the amount entered on line 5 of the “Required to File” worksheet. Joe is required to file. His income counts in the Medicaid budget. See Computation 2 below.

Computation 1 Computation 2 1. Earned Income + $450 = ($2,750 + $450) $3,200 1. Earned Income + $450 = ($2,750 + $450) $3,200 2. Minimum Amount $1,350 2. Minimum Amount $1,350 3. Enter Larger of Lines 1 & 2 $3,200 3. Enter Larger of Lines 1 & 2 $3,200 4. Maximum Amount $15,750 4. Maximum Amount $15,750 5. Enter Smaller of Lines 3 & 4 $3,200 5. Enter Smaller of Lines 3 & 4 $3,200 6. Dependent’s Gross Income ($2,750 + $200) $2,950 6. Dependent’s Gross Income ($2,750 + $600) $3,350 Joe is not required to file because $2,950 is less than $3,200 (Line 6 is less than Line 5). His income does not count in the Medicaid budget for his parents’ and/or siblings’ eligibility. Joe is required to file because $3,350 is more than $3,200 (Line 6 is greater than Line 5). His income counts in the Medicaid budget for his parents’ and/or siblings’ eligibility.

Appendix A-20-1

Revise Date: 10/2019

Lottery and Gambling Winnings: Months over which Income is Counted by Income Increment

From $ Up To $ # Months Counted for Medicaid 1 79,999 1 80,000 89,999 2 90,000 99,999 3 100,000 109,999 4 110,000 119,999 5 120,000 129,999 6 130,000 139,999 7 140,000 149,999 8 150,000 159,999 9 160,000 169,999 10 170,000 179,999 11 180,000 189,999 12 190,000 199,999 13 200,000 209,999 14 210,000 219,999 15 220,000 229,999 16 230,000 239,999 17 240,000 249,999 18 250,000 259,999 19 260,000 269,999 20 270,000 279,999 21 280,000 289,999 22 290,000 299,999 23 300,000 309,999 24 310,000 319,999 25 320,000 329,999 26 330,000 339,999 27 340,000 349,999 28 350,000 359,999 29 360,000 369,999 30 370,000 379,999 31 380,000 389,999 32 390,000 399,999 33 400,000 409,999 34 410,000 419,999 35 From $ Up To $ # Months Counted for Medicaid 420,000 429,999 36 430,000 439,999 37 440,000 449,999 38 450,000 459,999 39 460,000 469,999 40 470,000 479,999 41 480,000 489,999 42 490,000 499,999 43 500,000 509,999 44 510,000 519,999 45 520,000 529,999 46 530,000 539,999 47 540,000 549,999 48 550,000 559,999 49 560,000 569,999 50 570,000 579,999 51 580,000 589,999 52 590,000 599,999 53 600,000 609,999 54 610,000 619,999 55 620,000 629,999 56 630,000 639,999 57 640,000 649,999 58 650,000 659,999 59 660,000 669,999 60 670,000 679,999 61 680,000 689,999 62 690,000 699,999 63 700,000 709,999 64 710,000 719,999 65 720,000 729,999 66 730,000 739,999 67 740,000 749,999 68 750,000 759,999 69 760,000 769,999 70

Appendix A-20-2 Revise Date: 10/2019

From $ Up To $ # Months Counted for Medicaid 770,000 779,999 71 780,000 789,999 72 790,000 799,999 73 800,000 809,999 74 810,000 819,999 75 820,000 829,999 76 830,000 839,999 77 840,000 849,999 78 850,000 859,999 79 860,000 869,999 80 870,000 879,999 81 880,000 889,999 82 890,000 899,999 83 900,000 909,999 84 910,000 919,999 85 920,000 929,999 86 930,000 939,999 87 940,000 949,999 88 950,000 959,999 89 960,000 969,999 90 970,000 979,999 91 980,000 989,999 92 990,000 999,999 93 1,000,000 1,009,999 94 1,010,000 1,019,999 95 1,020,000 1,029,999 96 1,030,000 1,039,999 97 From $ Up To $ # Months Counted for Medicaid 1,040,000 1,049,999 98 1,050,000 1,059,999 99 1,060,000 1,069,999 100 1,070,000 1,079,999 101 1,080,000 1,089,999 102 1,090,000 1,099,999 103 1,100,000 1,109,999 104 1,110,000 1,119,999 105 1,120,000 1,129,999 106 1,130,000 1,139,999 107 1,140,000 1,149,999 108 1,150,000 1,159,999 109 1,160,000 1,169,999 110 1,170,000 1,179,999 111 1,180,000 1,189,999 112 1,190,000 1,199,999 113 1,200,000 1,209,999 114 1,210,000 1,219,999 115 1,220,000 1,229,999 116 1,230,000 1,239,999 117 1,240,000 1,249,999 118 1,250,000 1,259,999 119 1,260,000 or higher 120

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 1 Effective Month: March 2019 Contents 100.01 HISTORY AND LEGAL BASE ............................................................................................... 3 100.02 AGENCY DUTIES ................................................................................................................... 5 100.02.01 DUTIES OF THE DIVISION OF MEDICAID (DOM) ................................................. 5 100.02.02 DUTIES OF THE DEPARTMENT OF CHILD PROTECTIVE SERVICES (DCPS) ............................................................................................................................................................. 6 100.03 RIGHTS OF APPLICANTS AND RECIPIENTS.................................................................. 7 100.03.01 OPPORTUNITY TO APPLY ......................................................................................... 7 100.03.02 CIVIL RIGHTS AND NON-DISCRIMINATION .......................................................... 7 100.03.03 ACCESS TO INFORMATION ...................................................................................... 7 100.03.04 CONFIDENTIALITY OF INFORMATION ................................................................... 8 100.03.05 PROTECTED INFORMATION ..................................................................................... 9 100.03.06 RELEASE OF PROGRAM INFORMATION ............................................................ 10 100.03.07 SAFEGUARDING CONFIDENTIAL INFORMATION ............................................. 10 100.03.08 SAFEGUARD AWARENESS TRAINING ................................................................. 11 100.04 ELIGIBILITY APPEALS AND FAIR HEARINGS .............................................................. 12 100.04.01 THE HEARING PROCESS ........................................................................................ 13 100.04.02 EXPEDITED HEARINGS ............................................................................................ 20 100.04.03 CONTINUATION OF BENEFITS .......................................................................... 23 100.04.04 PREPARATION OF THE HEARING RECORD ...................................................... 24 100.04.05 HOLDING THE LOCAL HEARING............................................................................ 25 100.04.06 ISSUING THE LOCAL HEARING DECISION ......................................................... 26 100.04.07 TAKING ACTION ON THE CASE ............................................................................. 27 100.04.08 STATE HEARING REQUESTED AFTER ADVERSE LOCAL DECISION ....... 27 100.04.09 STATE HEARINGS...................................................................................................... 28 100.04.10 REVIEW BY STATE HEARING OFFICER .............................................................. 28 100.04.11 HOLDING THE STATE HEARING ............................................................................ 29

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 2 Effective Month: March 2019 100.04.12 RECESSING OR CONTINUING A STATE HEARING .......................................... 29 100.04.13 CHANGES WHICH OCCUR DURING THE HEARING PROCESS .................... 30 100.04.14 REVIEW BY DDS STAFF ........................................................................................... 31 100.04.15 RECOMMENDATION OF THE STATE HEARING OFFICER .............................. 31 100.04.16 DECISION OF THE AGENCY ................................................................................... 31 100.04.17 REGIONAL OFFICE RESPONSIBILITIES IN THE HEARING PROCESS ........ 32 100.04.18 TIMELINESS OF HEARING ACTIONS – RO RESPONSIBILITIES.................... 33 100.05 IMPROPER PAYMENTS...................................................................................................... 35 100.05.01 IMPROPER PAYMENT REPORTING................................................................... 39 100.05.02 CLAIMS AGAINST ESTATES ................................................................................ 43 100.06 QUALITY CONTROL ............................................................................................................ 44 100.06.01 MEQC DISAGREEMENT RESOLUTION PROCESS ........................................ 45 100.06.02 FAILURE TO COOPERATE WITH MEQC .............................................................. 45 100.06.03 CORRECTIVE ACTION ........................................................................................... 46

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 3 Effective Month: March 2019 100.01 HISTORY AND LEGAL BASE Title XIX of the Social Security Act, enacted in 1965, provides authority for states to establish Medicaid programs to provide medical assistance to needy individuals. The program is jointly financed by federal and state governments and administered by states. Within broad federal rules, each state decides eligible groups, types and range of services, payment levels for services, and administrative and operating procedures. Payments for services are made directly by the state to the providers that furnish the services. Background Enabling legislation for the Medicaid program in Mississippi was enacted during a special session of the legislature in 1969. Funds were appropriated and the Mississippi Medicaid Commission was designated as the single state agency to administer the program. State statutes governing Medicaid may be found in Sections 43-l3-l0l et. seq. of the Mississippi Code of 1972. From 1969 to 1973, the determination of Medicaid eligibility was the responsibility of the State Department of Public Welfare (DPW). During this time period, DPW authorized money payments for the aged, blind and disabled and dependent children. SSI Program The passage of Public Law 92-603 amended Title XVI of the Social Security Act and established the Supplemental Security Income (SSI) Program for the aged, blind and disabled. State statutes were amended to specify that DPW would no longer determine eligibility for a monthly payment for the aged, blind and disabled. PL 92-603 allowed States an option to either grant Medicaid to all persons receiving SSI (known as Section 1634) or to grant Medicaid to persons who met more restrictive criteria set by States (known as 209b). The Mississippi Legislature voted to limit Medicaid eligibility to persons who met more restrictive criteria and to designate the DPW as the certifying agency for Medicaid. During the l980 session of the Mississippi Legislature, Senate Bill 2118 changed the Medicaid eligibility criteria to 1634 status whereby Medicaid would be granted to all

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 4 Effective Month: March 2019 individuals receiving SSI. In addition, SSI criteria would be used to determine eligibility for all aged, blind and disabled individuals. During the 1981 Legislative Session, Senate Bill 2478 authorized the Mississippi Medicaid Commission to make its own Medicaid determinations for aged, blind and disabled individuals. Regional Medicaid offices were opened in July 1981, for the purpose of certifying the eligibility of aged, blind and disabled individuals who did not receive SSI cash assistance. Current Structure Senate Bill 3050, entitled the “Mississippi Administrative Reorganization Act of 1984,” transferred the powers and responsibilities of the Mississippi Medicaid Commission to the Division of Medicaid in the Office of the Governor. The Division of Medicaid is the single state agency designed to administer the Medicaid Program. The Mississippi Department of Human Services (MDHS, formerly known as DPW) continued to determine eligibility for the Medicaid Programs for children and families as authorized under Section 43-13-115 of the Mississippi Code of 1972, Annotated, and later adding determination of eligibility for Children’s Health Insurance Program (CHIP) in 1999 under Section 41-86-15. During the 2004 Session of the Mississippi Legislature, House Bill 1434 made significant changes to Section 43-13-115 of the Mississippi Code of 1972. While retaining all Medicaid coverage groups and CHIP (Section 41-86-1 and so forth), the Division of Medicaid was given the responsibility for determining initial and ongoing eligibility for all children, families, and pregnant women. The transition of the Families, Children and CHIP (FCC) programs from MDHS to Division of Medicaid was effective January 1, 2005. During the 2012 Session of the Mississippi Legislature, House Bill 316 transferred the existing contract for insurance services for the Children’s Health Insurance Program (CHIP) from the State and School Employees Health Insurance Management Board to the Division of Medicaid effective January 1, 2013. The Division of Medicaid has all authority set forth in 43-13-101 et seq. in administering the Children’s Health Insurance Program (CHIP).

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 5 Effective Month: March 2019 DHS remained the certifying agency for children under Title IV-E services and other related custody and adoption assistance and those eligible for Medicaid coverage under the Refugee Resettlement grant program until the creation of the MS Department of Child Protection Services with the passage of Senate Bill 2179 during the 2016 Legislative Session. MDCPS is now the lead child welfare agency and effective July 1, 2016, became responsible for Medicaid certifications for children in the custody of MDCPS who qualify for Medicaid and all IV-E foster children and adoption assistance children and the refugees qualifying for Medicaid under the Refugee Resettlement Grant. During the 2018 legislative session, the passage of Senate Bill 2675 made the Department of Child Protection Services a sub-agency independent of, though housed within, the Department of Human Services. The restructuring included the sharing of resources between the two agencies, such as systems support and other related administrative supports, to enhance efficiency. 100.02 AGENCY DUTIES 100.02.01 DUTIES OF THE DIVISION OF MEDICAID (DOM) The duties of the Division of Medicaid as set out by State and Federal legislation and the approved State Plan include, but are not limited to: • Setting regulations and standards for the administration of the Medicaid programs, with approval of the Governor and in accordance with the Administrative Procedures Law. • Providing Medicaid coverage to all qualified beneficiaries under the provisions of state law and within appropriated funds. • Establishing reasonable fees, charges and rates for medical services, drugs, equipment and supplies. • Fair and impartial hearings. • Safeguards for preserving the confidentiality of records. • Detecting, investigating and processing alleged violations, fraudulent practices and abuses of the program.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 6 Effective Month: March 2019 • Receiving and expending funds for the program • Submitting a state plan for Medicaid in accordance with state and federal regulations. • Preparing and distribution of required reports to the state and federal government. • Defining and determining the scope, duration, and amount of Medicaid coverage. • Cooperating and contracting with other state agencies for the purpose of administering the Medicaid program. • Bringing suit in its own name. • Recovering incorrect beneficiary or provider payments including recovery of beneficiary or provider state tax refunds of beneficiaries or providers. • Establishing and providing methods of administration for the operation of the Medicaid program. • Contracting with the federal government to provide Medicaid to certain refugees. • Entering into an agreement with the federal health insurance marketplace as necessary to fulfill the requirements of federal healthcare laws relating to insurance affordability programs that include Medicaid, CHIP and subsidies for insurance coverage through a federal marketplace, effective January 1, 2014. 100.02.02 DUTIES OF THE DEPARTMENT OF CHILD PROTECTIVE SERVICES (DCPS) The duties of DCPS regarding Medicaid include: • Providing the opportunity for persons to apply for Medicaid benefits through all foster care and refugee programs. • Determining time-limited Medicaid eligibility for certain refugees under the Refugee Resettlement Grant administered by MCPS. • Determining eligibility for foster children and adoption assistance-related Medicaid applicants and certifying them as eligible, notifying them of eligibility and determining retroactive eligibility, when appropriate. • Renewing foster care and adoption assistance Medicaid eligibility at required intervals. • Providing the opportunity for filing appeals and conducting hearings for eligibility certifications that MCPS certifies.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 7 • Identifying and reporting third party resources for foster care and adoption assistance recipients. 100.03 RIGHTS OF APPLICANTS AND RECIPIENTS Any individual applying for and/or receiving assistance has certain rights relating to receipt of Medicaid benefits, which are addressed in this section. 100.03.01 OPPORTUNITY TO APPLY Any individual who requests assistance, including those who are clearly ineligible, must be allowed to apply immediately. Medicaid Specialists must make a reasonable effort to assist the applicant in establishing eligibility. 100.03.02 CIVIL RIGHTS AND NON-DISCRIMINATION The Division of Medicaid complies with all state and federal policies which prohibit discrimination based on race, age, sex, national origin, handicap or disability as defined through the Americans with Disabilities Act of 1990, the Rehabilitation Act of 1973 and the Civil Rights Act of 1964. All complaints of discrimination will be investigated in accordance with state and federal laws and regulations. 100.03.03 ACCESS TO INFORMATION The applicant, recipient or his authorized/designated representative may have access to information in the eligibility case record by requesting copies of information from the file, in certain situations and under specified conditions as required by the Health Insurance Portability and Accountability Act (HIPAA) of 1996 Act. The privacy restrictions for protected health information (PHI) under HIPAA laws are very specific regarding disclosure of information to and on behalf of a Medicaid applicant or beneficiary. For a complete discussion of privacy policies and privacy procedures for all disclosures and the authorizations forms required prior to releasing case record information, refer to HIPAA Privacy Policies and HIPAA Privacy Procedures located on the DOM website. Effective Month: July 2025

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 8 Effective Month: March 2019 HIPAA Privacy Procedures outline the requirements for the release of information, with or without the consent of the beneficiary, and the type and amount of information that is allowed to be released to or for: • A Medicaid applicant or recipient, referred to as a beneficiary, • A personal or legal representative of a beneficiary, • A parent or guardian of a minor beneficiary, • Law enforcement agencies or officials, • Public authorities, • A judicial or administrative hearing, • Federal/state agencies, • Audits or compliance reviews, • Legislators or elected officials, • Providers and their contractors. 100.03.04 CONFIDENTIALITY OF INFORMATION All individuals have the right to a confidential relationship with the Division of Medicaid. All information maintained on recipients, former recipients and denied applicants is confidential and must be safeguarded. The Division of Medicaid (DOM) will adhere to state laws and federal regulations on the protection of the confidentiality of information about applicants/recipients. Protected information may only be disclosed without the individual’s authorization for purposes directly connected with the administration of the program. This includes: • Establishing eligibility, • Determining amount of medical assistance, • Providing services for recipients, and • Conducting or assisting an investigation, prosecution and civil or criminal proceeding related to the program. The Division of Medicaid will also adhere to the Health Insurance Portability and Accountability Act (HIPAA) as it relates to confidentiality of information about applicants/recipients. It is DOM’s policy that a valid authorization be obtained for all disclosures that are not for treatment, payment or healthcare operations, to the

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 9 Effective Month: March 2019 individual or their representative, to persons involved with the individual’s care, to business associates in their legitimate duties or as required by law. The agency has specified the agencies, persons and circumstances under which applicant or recipient information may be released with or without a recipient’s consent. Any other exceptions are subject to prior approval of the DOM Executive Director or the Eligibility Deputy Administrator and DOM’s Privacy Officer. Refer to DOM HIPAA Privacy Procedures for a complete discussion of disclosure rules. 100.03.05 PROTECTED INFORMATION Protected information is of two general types: eligibility/financial and medical. It includes, but is not limited to, the following information: 1. Eligibility information • Name and address of applicants/recipients. • Social and economic conditions or circumstances. • Evaluation of personal information such as financial status, citizenship, residence, age and other demographic characteristics. • Information received in connection with the identification of legally liable third-party resources. • Information received for verifying income eligibility and benefit level. NOTE: Income information verifying income eligibility and benefit level received from the Social Security Administration, the Internal Revenue Service, the Veteran’s Administration, State Retirement Board or Medicare must be safeguarded according to the requirements of the agency that furnished the data. 2. Medical information • Medical data, including diagnosis and history of disease or disability. • Medical services provided. • Medical status, psycho behavioral status, and functional ability. • Results of laboratory tests.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 10 Effective Month: March 2019 • Medication records. * For a complete and detailed listing of information considered protected health information (PHI) refer to HIPAA Privacy Policies on the DOM website. 100.03.06 RELEASE OF PROGRAM INFORMATION No Medicaid data regarding recipients, providers or services may be released without prior approval of the Executive Director, unless an established exception applies. The following program information constitutes the only established exceptions which do not require prior approval of the Executive Director: • The annual report of the Division of Medicaid, published pursuant to state law, containing the total number of recipients, the total amount paid for medical assistance and care; the total number of applications, the total number of applications approved and denied, and similar data. • Pamphlets, brochures and other documents prepared for distribution to the public. • Information exchanged with other state or federal agencies pursuant to a contract or written agreement. If requests for information are received, including requests for large quantities of pamphlets, brochures and other public information, the regional office should forward them to the Office of Eligibility for further action. Requests will be considered pursuant to the Access to Public Records Act, as applicable. 100.03.07 SAFEGUARDING CONFIDENTIAL INFORMATION The privacy rule protects electronic records, paper records and oral communication. Therefore, employees of the agency are responsible for safeguarding the confidentiality

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 11 of recipient information in all forms to prevent unauthorized disclosure. In practical terms, this includes: • Following password and other security procedures for systems. • Securing cases in filing cabinets rather than leaving them in open view when not in use. • Discussing cases or recipients only as necessary for legitimate job-related purposes and in confidential office settings. Failure to abide by the policies and procedures regarding confidentiality of recipient and applicant information, either intentionally or unintentionally, can result in disciplinary action. In addition, any violation of privacy and security policies and procedures may be referred to state or federal agencies for prosecution. 100.03.08 SAFEGUARD AWARENESS TRAINING Training on the security standards for data provided by the Internal Revenue Service (IRS), the U.S. Citizenship and Immigration Services (USCIS) within the Department of Homeland Security (DHS) and the Social Security Administration (SSA) must be conducted annually for eligibility staff in each regional office. During the training employees are instructed in office security procedures to ensure security of the data and are issued a copy of the federal penalties for unauthorized disclosure of IRS, DHS and SSA information. A confidentiality statement for each type of data is signed by employees. The employee receiving the training must sign and date the confidentiality statements to certify receipt of security training for each agency’s data. The signed and certified statements are forwarded to state office, where they are maintained to document compliance with each agency’s safeguard training requirements. Effective Month: July 2025

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 12 100.04 ELIGIBILITY APPEALS AND FAIR HEARINGS At the time of any action affecting an applicant or recipient’s claim for assistance, the applicant or recipient or his representative (collectively referred to below as the “individual”) must be: • Informed of his right to a fair hearing and right to request an expedited fair hearing. • Notified of the methods by which he may obtain a hearing. • Informed of his right to represent himself at the hearing or to be represented by an authorized person such as an attorney, relative, friend or other spokesperson. • Notified of the time frames in which the agency must take final administrative action. The agency must grant the opportunity for a fair hearing to any individual who requests it because his claim for medical assistance is denied or not acted upon with reasonable promptness or because he believes that the agency has taken an action erroneously. Fair hearings must be accessible to individuals who are limited English proficient and to individuals with disabilities. A hearing request made in connection with a rebuttal prior to any adverse action being taken will not be accepted. NOTE: The agency need not grant a hearing when the sole issue is a federal or state law requiring an automatic change which adversely affects some or all recipients. Notification Regarding Appeal Rights If an interview is conducted, the right to appeal must be discussed with the individual. In addition, individuals are notified of appeal rights by statements included on the ABD and MAGI application forms and on all notices. A hearings pamphlet is included with adverse action notices informing individuals of the right to appeal and other information about the hearings process. These pamphlets are also available for distribution in regional offices and published on Division of Medicaid website. Effective Month: July 2025

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 13 Effective Month: July 2025 100.04.01 THE HEARING PROCESS Hearings Defined A fair hearing is an orderly, but informal meeting in which an individual is afforded an opportunity to address an impartial hearing officer for the purpose of presenting oral testimony and/or evidence of his entitlement to medical assistance and services. The individual has the right of confrontation and cross-examination as described further in this section. A fair hearing is a de novo hearing which means it starts over from the beginning. A new determination of eligibility is made based on all the evidence that can be secured, without regard to whether the evidence was available at the time the regional office acted. Thus, the process is not essentially different from a determination of eligibility. Types of Hearings The individual may request to present an appeal through a local-level standard or expedited hearing, a state-level standard or expedited hearing, or both. In an attempt to resolve issues at the lowest level possible, offices should encourage individuals to request a local hearing first. The only exception to requesting a local hearing is when the issue under appeal involves disability, blindness or level of care. Therefore, the actions below which involve medical decisions cannot be addressed in a local hearing. A state hearing must be requested for: • A disability or blindness denial or termination, or • A level of care denial or termination for the Katie Beckett Program. Hearing Methods Local and/or state level hearings (standard or expedited) will be held by telephone unless, at the discretion of the hearing officer, it is determined that an in-person hearing is necessary.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 14 Effective Month: March 2019 Regional Office Handling Local Hearing Request An appeal will ordinarily be filed in the regional office responsible for the adverse decision or delay in action. If the applicant or recipient has moved to another regional office’s jurisdiction at the time the appeal is made, it is possible for the regional office serving the current county of residence to act for the former regional office. However, the hearing officer may request the participation of staff in the regional office where the action was originally taken if necessary or advisable. Representation The request for a state or local standard or expedited hearing can be made in any of the following ways: in person, via mail, by telephone, or through other commonly accepted electronic means, i.e., fax, e-mail, or online through common web portal. “Legal representative” includes an authorized representative, an attorney retained to represent the applicant or recipient, a paralegal representative with a legal aid service, the parent of a minor child (if the applicant or recipient is a child), a legal guardian or conservator or an individual with power of attorney for the applicant or recipient. All legal representatives must be designated in writing using the appropriate DOM authorization form. The applicant or recipient may be represented by anyone he designates. If the applicant or recipient elects to be represented by someone other than an authorized, designated or legal representative, he must designate the person in writing using the appropriate DOM authorization form. If a person, other than a legal representative, states that an applicant or recipient has designated him as a representative and the applicant or recipient has not provided written verification to this effect, the regional office will ask the person to obtain written designation from the applicant or recipient using the appropriate DOM authorization form.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 15 Telephone Hearing Requests An oral request for a hearing made by telephone must be documented in written form by staff handling the call. The specialist will complete the appropriate hearing request form, i.e., DOM 350, Request for Local Hearing, or DOM 352, Request for State Hearing, and sign the form to begin the appeal process via the telephone request. Written Hearing Requests When a written request is received, the specialist or supervisor will complete the DOM 350 Request for Local Hearing or DOM 352 Request for State Hearing and sign the form to begin the appeal process. Any written request received from the client will be attached to the DOM 350 or DOM 352. The request may be submitted to the regional or central office by mail, in-person or by fax or by electronic means. An original signature is not required to be a valid hearing request. If the hearing request does not specify the type of hearing desired, the specialist will contact the person making the request to determine whether a local or a state hearing is being requested. If contact cannot be made within three (3) days of receipt of the hearing request, the regional office will assume a local standard hearing is requested and schedule accordingly. However, if the hearing involves a medical decision, which requires that a state hearing be held or if a state hearing is requested, the request will be forwarded to the Office of Administrative Appeals in the Central Office for assignment to a hearing officer. Hearing Requests Made in Person The individual may come to the regional office or meet with a specialist in person to request a hearing. The specialist must first determine what level of hearing, local or state, is desired. If a state level hearing is required because the hearing request is based on a medical decision, this will be explained to the individual. Otherwise, if the individual is unsure of the type hearing desired, the specialist will explain the difference between the two levels of appeal and types of hearings, standard or expedited and explain a state hearing may still be available if the local hearing decision is not favorable. The specialist will assist the individual in completing the appropriate form, DOM-350 or DOM 352, whichever is applicable. If a state hearing is required or Effective Month: July 2025

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 16 Effective Month: March 2019 requested, the specialist can assist in submitting the request to the central office or the individual may choose to submit it himself. Appeal By Both Members of a Couple When both members of an eligible couple wish to dispute the action or inaction of the regional office that affects both applications and cases similarly and arose from the same issue, one or both members may file the request for a hearing. The couple will be assured that both may present evidence at the hearing and that the agency’s decision will be applicable to both. If both file a hearing request, two hearings will be registered, but they will be conducted on the same day and in the same place, either consecutively or jointly, according to the wishes of the couple. If it is their wish for only one of them to attend the hearing, this is permissible. Time Limit for Filing a Hearing Request The individual has 30 days from the date the appropriate notice is issued to request either a local or state hearing (standard or expedited). This 30-day filing period may be extended if the individual can show good cause for not filing within 30 days. Good cause includes, but may not be limited to, illness, failure to receive the notice, being out of state, or some other reasonable explanation. If good cause can be shown, a late hearing request may be accepted, provided the facts in the case remain the same. However, if the individual’s circumstances have changed or if good cause for filing a request beyond 30 days does not exist, a hearing request will not be accepted. If the individual wishes to have his eligibility reconsidered, he may reapply. Timeframe for Entire Hearing Process (Local and/or State Hearings) The Division of Medicaid must take final administrative action on standard hearings, whether state and/or local, within 90 days of the date of the initial request for a hearing. Although regulations allow 90 days, the agency will make every effort to hold hearings promptly and render decisions in a shorter timeframe. The 90-day period for final administrative action must be met except in unusual circumstances when:

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 17 Effective Month: March 2019 • The agency cannot reach a decision because the client requests a delay or fails to take a required action, or • There is an administrative or other emergency beyond the agency’s control. All delays must be documented in the hearing record or case record, as appropriate. Scheduling the Hearing Upon receipt of a request for a hearing, the request will be acknowledged in writing and the hearing scheduled. If a local hearing is requested the regional office will notify the individual in writing of the time and date of the local hearing. A copy of the letter scheduling the local hearing will be filed in the case record. If a state hearing is requested, the hearing officer assigned to the case will notify the appropriate person in writing of the time and date of the state hearing. A request for an expedited hearing must be handled in accordance with 100.04.02, Expedited Hearings, described below. The notice scheduling the time and date of a state or local standard hearing must be mailed to the individual at least five (5) days before the day the hearing is scheduled. A hearing pamphlet will be included with the letter scheduling either a local or state hearing. Expedited hearing must be scheduled, held and a decision reached within a 7-working daytime period, as addressed in 100.04.02. Attendance at the Hearing A state or local standard or expedited hearing is not open to the public. All persons attending the hearing will attend for the purpose of giving information on behalf of the applicant or recipient or rendering him assistance in some other way, or for the purpose of representing the Division of Medicaid. All persons attending the hearing will be asked to give information pertinent to the issues under consideration.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 18 Effective Month: March 2019 Withdrawn or Abandoned Hearings The hearing process is initiated by a documented request. The request for hearing can be withdrawn by the individual using any of the methods for requesting a hearing – in person, via mail, by telephone, or by other electronic means, i.e., fax, email, or online via common web portal. A state or local standard or expedited hearing request may be withdrawn at any time prior to the scheduled hearing or after the hearing is held, but before a decision is rendered. For telephonic, online, and other electronic withdrawals, the agency must send the affected individual written confirmation via regular mail or electronic notification in accordance with the individual’s communication preference election. A hearing request will be considered abandoned if the appropriate individual fails to appear or is unavailable for a scheduled hearing without good cause. If no one is available for a hearing, the appropriate office will notify the individual in writing that the hearing is dismissed unless good cause is shown for not attending. Following failure to appear for a hearing, the proposed adverse action will be taken on the case if the action is not already in effect. Rights of the Individual The individual has the following rights in connection with a local or state hearing: • The right to examine at a reasonable time before the date of the hearing and during the hearing the contents of the individual’s case record. • The right to have legal representation at the hearing and to bring witnesses. • The right to produce documentary evidence and establish all pertinent facts and circumstances concerning eligibility. • The right to present an argument without undue interference and to question or refute testimony or evidence, including an opportunity to confront and cross-examine adverse witnesses.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 19

Effective Month: March 2019 Group Hearings A group hearing can be held for several applicants or recipients under the following circumstances: • The Division of Medicaid may consolidate the cases and conduct a single group standard hearing when the only issue involved is one of a single law or agency policy. • The applicants or recipients may request a standard group hearing when there is one issue of agency policy common to all of them. In all group hearings, whether initiated by the Division of Medicaid or by the applicants or recipients, the policies governing fair hearings must be followed. Each individual applicant or recipient in a group hearing must be permitted to present his own case and be represented by his own lawyer or representative or withdraw from the group hearing and have his appeal heard individually. As in individual hearings, the hearing will be conducted on the issue being appealed, and each applicant or recipient is expected to keep his testimony within a reasonable time as a matter of consideration to the others involved. Medicaid Determinations Made by Other Agencies Medicaid eligibility determinations that are made by the Social Security Administration (SSA) and certified to the Division of Medicaid are not subject to the administrative hearing procedures of DOM but are subject to the administrative hearing procedures of SSA. Appeals of an SSI denial or termination must be filed with SSA since that is the agency that determined eligibility for both SSI and Medicaid for the SSI applicant/recipient. However, appeals of eligibility decisions made by the Department of Child Protective Services (DCPS) for foster children whose eligibility was certified by DCPS and appeals of eligibility decisions made by the State Department of Health for Breast and Cervical Cancer for women screened and diagnosed through the Health Department are handled by the Division of Medicaid as state level appeals.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 20

Effective Month: March 2019 100.04.02 EXPEDITED HEARINGS An expedited hearing, either local or state, must be granted if the agency determines that the 90-day timeframe described in “Timeframe for the Entire Hearing Process (Local and/or State Hearings)” could jeopardize the individual’s life, health or ability to attain, maintain or regain maximum function, i.e., the medical urgency of the individual’s situation must be taken into consideration. An expedited hearing must be granted if the individual attests to an immediate need for a health service or services that, if delayed, could jeopardize the individual’s life or health. Take the following into consideration in making the decision to approve or deny a request for a local expedited hearing. • Does the individual currently have health insurance. If the individual has current coverage, Medicaid and Medicare included, that provides major medical coverage that would cover the cost of an urgent medical procedure or treatment then an expedited hearing would not be granted. • If the individual is a terminated recipient who requested continuation of benefits within 15 days of the adverse action notice and benefits are continued, an expedited hearing would not be granted. • Does the individual have an urgent medical procedure or treatment scheduled, or an urgent procedure/treatment that needs to be scheduled that may indicate a need for an expedited hearing. For example, an uninsured high risk pregnant woman attesting to the need for urgent pre-natal care may qualify for an expedited hearing. • If there is no medical urgency attested to in the request, an expedited hearing will not be granted. The hearing request will be handled as a standard hearing. • Expedited hearings apply to both MAGI and ABD denied or terminated individuals. However, for ABD purposes, if disability or level of care for a disabled child is the issue under appeal, it must be handled as an expedited state hearing. Expedited appeal requests may be submitted in person, by mail, by electronic submission or orally, as described below. A request for an expedited local hearing will be granted or denied by the regional office. A request for an expedited state hearing will be granted or denied by the Office of Appeals. If the regional office receives the request for an expedited state

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 21

Effective Month: March 2019 hearing, fax documentation of the request to the Office of Appeals upon receipt and follow up by mailing the written request to the Office of Appeals. Requests for an Expedited Hearing Due to the time constraints imposed for an expedited hearing and the medical urgency of such a request, prompt and timely action must be taken when the RO becomes aware an expedited appeal is requested. The date the request becomes known by whatever means is the date the expedited appeal request is received. • If the expedited hearing is granted, the individual will be notified in writing by use of form DOM-351A, Notice of Decision on Request for Expedited Local Hearing that includes the date, time and specifics of the hearing. Use of DOM- 350, Request for a Local Hearing, accommodates a request for an expedited hearing. An alternate form of written request can be accepted but must provide the reason an expedited hearing is needed, i.e., describe the medical urgency. • If the expedited hearing request is denied, DOM-351A, Notice of Decision on Request for Expedited Local Hearing, is used to notify the individual of the negative decision and reason(s) for denial. It also advises the eligibility hearing request will be treated as a standard hearing with separate notification of date, time and location. • If the regional office has already received a request for a hearing and the individual subsequently requests an expedited hearing, document the case with the date the expedited hearing was requested and how the expedited request was made - in person, via fax, by telephone, or other electronic means - and the reason the individual is requesting an expedited hearing. o If a local hearing has not been held, take action to grant or deny the local expedited decision as described above. o If a local hearing has already been held and the individual requests an expedited hearing, an additional local hearing is not required. DOM-351, Notice of Decision on Local Hearing, notifies the individual of the expedited hearing decision. The individual has the right to request a state hearing if the local hearing is adverse.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 22 Effective Month: March 2019 Notice to Grant or Deny a Request for an Expedited Hearing If a local expedited hearing is requested, the regional office must notify the individual as expeditiously as possible of the decision to grant or deny the request. This is done by telephone or in-person contact. After oral contact is made or if attempts to contact are unsuccessful, the regional office must follow up with written notice of the decision by use of DOM-351A, Notice of Decision on Request for Expedited Local Hearing. • If the expedited request is granted, the written notice will both approve the request and provide a date, time and specifics for the hearing. It is permissible to give the hearing date to the individual orally when advising that the expedited request has been granted, but a follow up written notice is also required. Allow adequate time for the individual to participate in the hearing while adhering to the 7-day timeframe allowed for the entire hearing process to be finalized. • If the expedited request is denied because there is no medical urgency or no treatment or procedure needed that will not be covered by existing health coverage, there are no further appeal rights associated with an expedited hearing denial. A denial of a request for an expedited hearing results in the request for an expedited appeal being treated as a standard request for a local hearing. The notice advises that a local hearing will or has been scheduled. If the regional office has already received a request for a standard hearing and the individual subsequently requests that the hearing be expedited, document the case with the date the expedited hearing was requested and how the request was made (in person, via fax, by telephone or other electronic means) and the reason the individual is requesting an expedited hearing.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 23 Effective Month: March 2019 Expedited Hearing and Hearing Decision Expedited local hearings that are granted are held in the usual manner, in-person or by telephone. Granting an expedited hearing means the hearing is scheduled, conducted and a decision rendered expeditiously. It does not mean that any policy or procedures associated with the eligibility process are disregarded. All factors of eligibility must be met, and all required verifications received as with all eligibility decisions. Individuals granted an expedited local hearing must be issued a hearing decision no later than seven (7) working days from the date the initial request for an expedited hearing request was received. Any delays in meeting the 7-day timeframe must be due to failure on the part of the client to take a required action or an administrative or other emergency beyond the agency’s control. All delays in reaching an expedited decision must be documented in the case record. The expedited appeal decision is treated the same as standard local level hearing decisions as outlined in 100.04.06, Issuing the Local Hearing Decision. The individual has the right to request a state level appeal and has the right to request an expedited appeal. DOM-352, Request for a State Hearing, allows an individual to request a state hearing either after a local hearing or to request only a state hearing and includes the option for an expedited state hearing. 100.04.03 CONTINUATION OF BENEFITS If a recipient or his representative requests a hearing within the advance notice period, benefits must be continued or reinstated to the benefit level in effect prior to the planned adverse action for both Medicaid and CHIP. Benefits will continue at the original or former level until a final hearing decision is rendered. As stated, if continuation of benefits is applicable, an expedited hearing request will not be granted. NOTE: The override function in MEDS may be used to reinstate QMB benefits for prior months pending the outcome of a hearing.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 24 Timely Request for Continuation of Benefits To determine if the request for continuation of benefits is timely, the request must be received by the regional office within 15-days from the notice date. This 15-day period includes the 10-day adverse action period plus 5 days mailing time. Any hearing requested or dated after this period will not be accepted as a timely request for continuation of benefits, unless the individual presents valid evidence to support that the notice was not received within the 5-day mailing time. Continuation of Benefits When Local Decision is Adverse The recipient may request a state hearing if the local hearing is adverse. If benefits have been continued pending the local hearing, then benefits will continue pending a state hearing decision provided the request for the state hearing is made within 15 days of the date on the Notice of Local Hearing Decision. Local and state hearing procedures are discussed later in this section. Agency Action Upheld in Final Hearing Decision When the final hearing decision is adverse to the recipient, the specialist will terminate or reduce the continued benefits using the original reason for the adverse action. The supervisor will waive notice at authorization since a second Notice of Adverse Action is not required. In addition, the Division of Medicaid has the right to initiate recovery procedures against the recipient to recoup the cost of any medical services furnished the recipient under Medicaid and CHIP premiums paid by DOM on behalf of CHIP children, to the extent they were furnished solely based on the provision for continuation of benefits. 100.04.04 PREPARATION OF THE HEARING RECORD A local hearing record is not needed since an applicant or recipient or his representative is entitled to examine the entire case record prior to or during the hearing; however, the regional office is responsible for preparing the hearing record to be used at a state hearing. The state hearing folder must be electronically submitted to the Office of Administrative Appeals in the Central Office no later than five (5) Effective Month: July 2025

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 25

Effective Month: March 2019 days after receipt of the request for a state hearing. The state hearing record will consist of all pertinent information relating to the issue under appeal, including: • The documented hearing request submitted by the individual. • A statement prepared by the specialist explaining the action taken on the case and the date of the action. In addition, there must be an explanation of any corrective action taken on the case after the hearing request. • Copies of portions of the case record which constitute the basis for the action taken on the case. All hearing records will contain a copy of the application form and the letters and notice(s) (electronic or manual) related to the action under appeal. • When applicable, a statement as to factors of eligibility not determined at the time of the denial or closure. For example, if the issue under appeal is a denial of disability but income was not established, a hearing on the disability factor will have limited value if the applicant or recipient was also ineligible on income or some other factor.

100.04.05 HOLDING THE LOCAL HEARING The regional office is responsible for scheduling and rendering decisions on local hearings.

Purpose of a Local Hearing The purpose of the local hearing is to provide an informal proceeding to allow the individual to: • Present new or additional information. • Question the action taken on the case. • Hear an explanation of eligibility requirements as they pertain to the individual’s situation.

Scheduling the Local Hearing When a request for a local hearing is received, the regional office will schedule the local hearing no later than 20 days after receipt of the request. The applicant or recipient will be allowed time to obtain additional information or request an attorney, relative or friend to attend the hearing and give evidence. The regional office may

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 26

Effective Month: March 2019 not schedule a local hearing without giving five (5) days advance notice to the individual unless the individual waives advance notice time. The case record will be documented if advance notice is waived.

Person Conducting the Local Hearing The regional office staff member who conducts the hearing must be one who has not participated in determining eligibility or directed the decision. Although a supervisor may have officially authorized the eligibility decision, if he/she has not actually taken part in the eligibility decision the supervisor will hold the hearing. However, if the supervisor made the actual determination of eligibility on the case, he/she cannot hold the local hearing and another person must be designated to conduct the hearing.

Preparing a Summary of the Hearing After a local hearing is held, the person who conducted the hearing will prepare a summary of the hearing procedure. The summary serves the same purpose as a transcript and is filed in the case record.

NOTE: The summary of the local hearing must be included as part of the state hearing record when a state hearing is requested after an adverse local hearing decision. The local hearing summary must contain sufficient information to enable the state hearing office to have a clear understanding of what transpired during the local hearing.

100.04.06 ISSUING THE LOCAL HEARING DECISION The regional office staff member who held the hearing will carefully review and consider the facts presented during the local hearing in rendering the local hearing decision. When a decision has been reached, the individual must be notified of the decision via DOM-351, Notice of Decision on Local Hearing. This form must be used since it advises the individual of the right to request a state hearing.

The DOM-351 must clearly state the reason for the decision and the policy which governs the decision. Also, if the hearing is denied, the new effective date of closure or reduced benefits must be included on the form if continuation of benefits applied

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 27

Effective Month: March 2019 during the hearing process. The new effective date of closure or reduced benefits must include an effective date at the end of the 15-day advance notice period allowed via DOM-351. A second Notice of Adverse Action is not required; therefore, the second eligibility notice should be waived at authorization if benefits are terminated or reduced because of the local hearing decision.

However, if a state hearing is subsequently requested within the 15-day advance notice period and continuation of benefits is applicable, the regional office will reinstate the individual’s eligibility pending the outcome of the state hearing.

100.04.07 TAKING ACTION ON THE CASE The regional office is responsible for taking any corrective action required because of a local or state hearing decision rendered in favor of the applicant or recipient or for processing the original planned action on the case which was the basis for the appeal if continuation of benefits applied pending the hearing decision.

100.04.08 STATE HEARING REQUESTED AFTER ADVERSE LOCAL DECISION As indicated, the individual has the right to appeal a local hearing decision by requesting a state hearing; however, the state hearing request must be made within 15 days of the mailing date of the DOM-351. This means the state hearing request must be received by the regional or central office on or before the 15th day after the local hearing notice is mailed. The state hearing request may be submitted to the regional or central office by mail, in-person, by fax or by other commonly accepted electronic means, such as fax, email, or online through common web portal. An original signature is not required to be a valid state hearing request. If benefits have been continued pending the local hearing decision, then benefits will continue throughout the 15-day advance notice period when the local hearing decision is adverse. If a state hearing is requested timely within the 15-day period, then benefits will continue pending the outcome of the state hearing.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 28

Effective Month: March 2019 State hearings requested after the 15-day advance notice period for the local hearing will not be accepted unless the 30-day period for filing a hearing request has not expired because the local hearing was held early in the 30-day period and there is time remaining.

100.04.09 STATE HEARINGS When a request for a state hearing is received in the regional office, the request will be noted with the receipt date and forwarded to the central office. A copy of the state hearing request will be retained for the case record. The regional office will proceed with preparation of the state hearing folder. The folder must be mailed within five (5) days of receipt of the state hearing request. If the request for a state hearing is submitted directly to state office, notification of the request will be forwarded to the appropriate regional office so the state hearing record can be prepared and sent in. A state hearing is assigned to an impartial hearing officer. Impartial means the hearing officer has not been involved in any way with the action or decision under appeal.

100.04.10 REVIEW BY STATE HEARING OFFICER Upon receipt of the state hearing folder, the hearing officer will review the material submitted. If the review shows an error was made in the action of the regional office or in the interpretation of policy or that there has been a change in policy, the hearing officer will discuss the issue with the Benefit Program Supervisor, over the regional office involved in the hearing and if appropriate, ask that an adjustment be made. The regional office will then discuss this matter with the individual. If the individual is agreeable to the adjustment of the claim, the state hearing request will be withdrawn. Otherwise, if the action of the regional office is in order, the hearing officer will request any additional information from the case record that appears to be needed and will schedule the hearing.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 29

Effective Month: March 2019 100.04.11 HOLDING THE STATE HEARING In conducting the hearing, the hearing officer will provide the following information to those present: • The hearing will be digitally recorded. This information is made available to the individual upon request. • An explanation of the individual’s rights during the hearing. • That the purpose of the hearing is for the individual to question the agency’s decision and present additional information or evidence. • The reason for the hearing, i.e., the action taken by the regional office which prompted the appeal. • That the case record is available for review by the individual during the hearing.

NOTE: Even though the state hearing officer uses a hearing folder to conduct the hearing, the actual case record must be available for review by the individual before, during or after the state hearing. • The final hearing decision will be rendered by the Executive Director of the Mississippi Division of Medicaid based on the facts presented at the hearing and the case record material and that the individual will be notified by letter of the final decision. During the hearing the individual will be allowed an opportunity to make a full statement concerning his appeal and will be assisted, if necessary, in disclosing all information on which the claim is based. All persons representing the applicant or recipient and those representing the regional office will have the opportunity to state all facts pertinent to the appeal. When all information has been presented, the hearing officer will close the hearing.

100.04.12 RECESSING OR CONTINUING A STATE HEARING If additional information is determined to be needed during the state hearing, the hearing officer may recess or continue the hearing as follows:

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 30

Effective Month: March 2019 Recessing the Hearing If additional information is needed and this information is readily available, the hearing officer will recess the hearing for the time required to obtain the facts.

Continuing the Hearing If the information needed is not readily available, the hearing officer will continue the hearing to a suitable later date. If the time at which the information will be obtained is known, the hearing officer, before adjourning the original hearing, will set the time and place for the continued hearing at the earliest possible date, notifying the principals that there will be no further notice. The hearing officer will reach an agreement with the applicant or recipient and any persons attending on his behalf about bringing the needed information to the continued hearing.

The hearing cannot be extended beyond the time limit for completion of a hearing.

100.04.13 CHANGES WHICH OCCUR DURING THE HEARING PROCESS If the regional office becomes aware of a change in circumstances of the applicant or recipient which will result in an adverse action other than the issue currently under appeal, the individual must be notified in writing. Adverse action notice requirements (10-day notice plus 5 days mailing time) must be met and action taken as follows:

Change Discovered Prior to State Hearing If the state hearing has not yet been held, the individual may choose to have the new adverse action issue incorporated into the current appeal; however, the individual must first request an appeal in the usual manner. If the new hearing request is filed in time for the issue to be considered in the current hearing process, the regional office will notify the hearing officer of the additional issue under appeal. In this instance, the hearing may have to be rescheduled to allow the individual time to prepare for the hearing. Change Discovered During the State Hearing If the change in circumstances is discovered during the actual hearing, the hearing officer will recess the hearing and notify the regional office to send an adverse

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 31 Effective Month: March 2019 action notice to the individual. The hearing will be reconvened after the adverse action notice is mailed and the advance notice period has expired. The individual may choose to include the new issue in the hearing when it is reconvened. The hearing will be reconvened following the usual procedure for setting the time and place. 100.04.14 REVIEW BY DDS STAFF When the issue under appeal is disability or blindness, a review by DDS is required. After the hearing, the hearing officer will forward all medical information to the Disability Determination Service for reconsideration. A review team consisting of medical staff who were not involved in any way with the original decision will review the medical information and hearing transcript and give a decision on the disability or blindness factor. The DDS decision is final and binding on the agency. 100.04.15 RECOMMENDATION OF THE STATE HEARING OFFICER After the hearing, the final decision of the hearing officer must be based on oral and written evidence, testimony, exhibits and other supporting documents which were discussed at the hearing. The decision cannot be based on any material, oral or written, not available to and discussed with the individual. Following the hearing, the hearing officer will make a written recommendation of the decision to be rendered because of the hearing. The recommendation, which becomes part of the state hearing record, will cite the appropriate policy which governs the recommendation. 100.04.16 DECISION OF THE AGENCY The Executive Director of the Division of Medicaid, upon review of the recommendation, proceedings and the record may sustain the recommendation of the hearing officer, reject the recommendation or remand the matter to the hearing officer for additional

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 32

Effective Month: March 2019 testimony and evidence, in which case the hearing officer will submit a new recommendation to the Executive Director after the additional action has been taken. As soon as possible after the hearing officer makes a recommendation, a written decision summarizing the facts and identifying the policies and regulations which support the decision will be prepared and mailed to individual, with a copy to the regional office, Bureau Director, Deputy, and the Deputy Administrator for Eligibility. The decision letter will specify any action to be taken by the agency and any revised eligibility dates. If the decision is adverse and continuation of benefits is applicable, the individual will be notified of the new effective date of reduction or termination of benefits or services, which will be fifteen (15) days from the mailing date of the notice of decision. The decision of the Executive Director of the Division of Medicaid is final and binding. The individual is entitled to seek judicial review in a court of appropriate jurisdiction. Should the individual file an appeal the second time without a change in circumstances or agency policy, the individual will be notified in writing by the appropriate office explaining that the appeal cannot be honored. If the individual’s circumstances or agency policy have changed, the individual will be advised to file a new application.

100.04.17 REGIONAL OFFICE RESPONSIBILITIES IN THE HEARING PROCESS Each Regional Office (RO) must have a system in place to track and monitor hearing requests from the date of receipt through the final appeal decision. • Each RO must promptly identify and document all hearing requests received by the office and immediately route the request to the appropriate person in the office assigned to handle hearing requests. This person will review the case record to ensure: o The proper person is filing the request, i.e., the person with authority to act for the individual. If not, contact the appropriate person to determine if a hearing needs to be requested. o An expedited hearing request is handled appropriately, i.e., the request is granted or denied according to policy and DOM-351A is issued

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 33

Effective Month: March 2019 accordingly. If granted, the hearing must be held and a decision issued within the timeframe allowed, i.e., 7-working days. o The action taken on the case was correct and all needed verifications are present in the record. If not, immediate corrective action is needed, and the individual so notified. o Continuation of benefits is authorized, if applicable. o That the case is assigned to the correct staff person who will schedule and hold the local hearing or that a state hearing request is correctly and promptly processed. • Each regional office is responsible for all activities involved in the local hearing process and for taking appropriate action on the case at the end of the hearing process in a timely manner as outlined in the chart below.

100.04.18 TIMELINESS OF HEARING ACTIONS – RO RESPONSIBILITIES Step 1. Determine timeliness of hearing request o All hearing requests have 30 days from date on the notice to request a hearing. o Terminations have 15 days from date on notice to have benefits continue and 30 days from the date on notice to request a hearing. o An expedited hearing request is subject to a 7-day timeframe for scheduling and holding the hearing and issuing a decision provided the request, oral or written, is received within 30-days from date on the notice. If continuation of benefits applies, an expedited hearing is not granted. o If hearing is not requested timely and there is no evidence to support the notice not being received within the advance notice period, issue written notice to the client that the hearing request will not be honored because time to request hearing expired. A new application would be required to appeal. o The agency has 90 days from the date of the hearing request to schedule, conduct and finalize a hearing. RO’s must handle hearing requests promptly, as soon as received, to ensure the hearing timelines described below are met.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 34

Effective Month: March 2019 Step 2. Determine the type of hearing requested or required. o DDS and Level of Care denials require a state level hearing – handle as state hearing. o If request does not specify type and issue is not DDS or LOC denial, contact client. If no contact within 3 days, assume a standard local hearing is needed and proceed. o If the request indicates medical urgency, evaluate whether an expedited local (or state if DDS or LOC at issue) is needed and handle accordingly.

Step 3. Re-examine action taken to determine if correct. o If correct, proceed to Step 4. o If incorrect, take corrective action and notify client. Step 4. Schedule local hearing, if appropriate. o Local hearings must be scheduled no later than 20 days after receipt of the request. o Schedule local hearing 5 days in advance, in writing. o Expedited hearings must be held, and a decision issued within 7-days of the request. Make telephone contact with individual to schedule hearing then follow up in writing via DOM-351A.

Step 5. Hold a local level hearing, if appropriate. o Must be held by supervisor not directly involved with the eligibility decision. o Expedited local hearing must be held as soon as possible to meet 7-day timeframe. o Prepare a local hearing summary. o Act on local hearing decision – corrective action as needed or uphold original RO decision. o If benefits have been continued pending the local hearing, continue benefits through advance notice period when local decision is adverse. o Client has 15 days from local hearing decision to request a state hearing whether benefits have continued or not. Exception is the original 30-day period for requesting a hearing has not expired which lengthens the time allowed. o Request for expedited state hearing following adverse local hearing must be referred to Office of Appeals on date written request for state hearing is received. Step 6. Prepare for state level hearing if applicable. o Prepare a state level hearing folder within 5 days of request for a state hearing: ➢ 5-days from original hearing request (Step 1), or ➢ 5-days from state hearing request following adverse local hearing.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 35

Effective Month: March 2019 ➢ If expedited state hearing is requested, hearing folder must be prepared and forwarded immediately upon receipt of the request to Office of Appeals. ➢ Ensure hearing folder has all required material. o Act on state level hearing decision when received. No additional notices are issued by RO. Hearing decision letter addresses all issues under appeal.

Changes Which Occur During the Hearing Process • A change that becomes known during the hearing process that is not related to issue under appeal is handled as a separate adverse action (requires 15-day notice). • New adverse action can be combined with current issue under appeal if time allows. • A change that becomes known during actual state hearing will result in a recess so that an adverse action notice may be issued by RO. New adverse action may be combined with state hearing when reconvened.

100.05 IMPROPER PAYMENTS When Medicaid benefits are available to recipients improperly, the central and regional office must identify these situations and take corrective action. Improper payments occur when the Medicaid or CHIP coverage authorized by DOM either underpays or overpays a recipient’s fee-for-service or managed care costs. An improper payment may be in the form of an underpayment or an overpayment. Corrective action includes recovering misspent funds directly from a recipient or from the recipient’s state tax refund. Improper payments situations include, but are not limited to, the following: • Begin or end dates of eligibility are incorrect or total ineligibility exists. • A category of eligibility is incorrectly assigned based on incorrect eligibility information entered in the system. • Incorrect Medicaid Income is calculated due to over or under reported income. • Policy is misapplied that impacts eligibility. • A case is not reviewed timely, or a change is not reported timely and the review or change results in benefits that should have been reduced or results in ineligibility. • A transfer of assets is discovered after eligibility has been approved.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 36

Effective Month: March 2019 • An applicant willfully or unintentionally withheld information that impacted eligibility.

Underpayments An underpayment occurs when Medicaid has not paid its full share of a recipient’s medical expenses or managed care payments. All underpayments are to be corrected upon discovery. If the underpayment resulted from agency error, the error may be corrected retroactively. Underpayments resulting from recipient errors are corrected, but they are not corrected retroactively. Necessary adjustments are made effective with the next month a change can be made. For further discussion, refer to the policy on reinstatements in Chapter 101. Overpayments An overpayment occurs because the recipient was ineligible for a period during which he received Medicaid or CHIP, or because Medicaid paid more than its correct share of medical expenses or managed care payments or more for institutional cost of care than it should have. An overpayment may result from the following: • Suspected Fraud The ABD and MAGI application forms carry a warning about the penalty for giving false information, so that when the individual gives the information to complete the application and signs it, he has been put on notice about giving incorrect or incomplete information as well as the requirement to report changes. Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some benefit to which the individual is not entitled or to a benefit greater than that to which the individual is entitled. It includes any act that constitutes fraud under applicable federal or state law.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 37 Effective Month: March 2019 Fraud is a serious charge to make, and the results can be serious. As a result, the facts in such a case must be clearly and accurately stated. The Mississippi courts have ruled, “There is a presumption against fraud, dishonesty and bad motive, and evidence to overcome this presumption must be more than mere preponderance; it must be clear and convincing. “ Although fraud is a question for courts to decide, the regional office must determine suspected fraud, i.e., whether there is a basis for belief that fraud may have been committed. In making this decision, the specialist must consider the individual’s intent, and the individual’s mental capacity. Also, a clear distinction, based on verified facts, must be made between misrepresentation with intent to defraud and mis-statements due to misunderstanding of requirements or of the individual’s responsibility to report information. It is also important to distinguish between suspected fraud and omission, neglect or error by regional office staff in helping the applicant or recipient to understand his responsibilities and in securing and recording pertinent information. An applicant or recipient may be suspected of fraud when the individual willfully and knowingly and with intent to deceive obtained Medicaid or CHIP by: ▪ Making a false statement or misrepresentation; or ▪ Failing to disclose a material fact; or ▪ Not reporting changes in income or other eligibility factors that affect the benefit; and ▪ As a result of the action or inaction, the individual obtains or continues to receive assistance. In other words, if the information had been known, it would have resulted in denial or reduction of benefits to the individual or would have resulted in a different amount of Medicaid Income.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 38

Effective Month: March 2019 • Client Error In situations involving client error, there is no proof that individual (applicant, recipient or his authorized representative) acted willfully and intentionally to obtain more benefits than those he was entitled to receive. Instead, the individual gave incomplete, incorrect or misleading information because he misunderstood, was unable to comprehend the relationship of the facts about his situation to eligibility requirements or there was other inadvertent failure on the individual’s part to supply the pertinent or complete facts affecting Medicaid or CHIP eligibility. The specialist must be alert to whether the individual understood that the information he gave or withheld had a bearing on his eligibility or the amount of his Medicaid Income. • Agency Error Agency errors occur in instances such as the following: o The specialist misapplies policy or fails to follow procedures which would have resulted in denial or closure if the correct action had been taken. o The specialist makes a mathematical error in the test for financial need; enters incorrect income or resource figures in the system, transposes figures or otherwise determines eligibility using incorrect income or resources when the correct information was available in the case record. o The redetermination is not completed timely, and the specialist subsequently finds information leading to ineligibility. In this instance all benefits received following the review due date are improper due to agency error. Had the review been completed timely, the case could have been closed to prevent improper benefits from being received.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 39

Effective Month: March 2019 o The specialist fails to act on a reported or anticipated change, fails to check information available to the agency or overlooks a clue which, if pursued to conclusion, would have led to a finding of ineligibility. Examples are: • Failure to follow-up when the individual reports that he expects a definite stated change in his income, living arrangement or other area impacting eligibility. • Failure to follow-up when an applicant or recipient is asked to apply for a possible benefit, such as Social Security, veteran’s benefits, unemployment compensation or other retirement or disability benefits. • Failure to follow-up when the individual reports a plan to sell, transfer, or otherwise dispose of his property, real or personal, or to buy or acquire property otherwise. • Failure to check data sources for unreported income. ▪ The central or regional office, through system or human oversight or failure, authorizes or continues eligibility to an ineligible person or improperly computes Medicaid Income. There are no exceptions for taking corrective action to resolve an agency or client caused error and there are no exceptions for preparing and submitting an Improper Payment Report for improperly paid Medicaid or CHIP benefits when one is applicable.

100.05.01 IMPROPER PAYMENT REPORTING Completion of the Improper Payment Report by Regional Office Form DOM-354, Improper Payment Report, will be prepared to report improper payments for ABD and MAGI. The 354 should be completed no later than the month following the month of discovery according to form instructions with the following information included: • The factor of eligibility involved, and how the information given or withheld affects eligibility or Medicaid Income.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 40 Effective Month: March 2019 • What the individual said about the factor in question and the date on which the information was given, whether the individual gave statements on the application or gave them verbally to the specialist and the reason the individual gave for withholding or falsifying the information. • The date on which and the circumstances under which the specialist learned of the correct information. • Steps the specialist has taken to verify the correct information. For example, securing bank statement, checking property records, contact with insurance company or employer, etc. • Whether the specialist considers the withholding or giving incorrect information to be willful, whether the individual was able to understand reporting responsibilities for giving accurate information and the meaning of his failure to do so. • Whether the applicant or recipient (and spouse) have resources from which to repay the amounts improperly received. Instances to Delay Preparation of the Report Preparation of the Improper Payment Report should be delayed as follows: • If a transfer of resources is involved, DOM-322 must be issued and an opportunity for rebuttal offered; therefore, preparation of the Improper Payment Report must be delayed until after the period for rebuttal is over. • If substantial home equity is discovered and verified, a DOM-314 must be issued, and an Improper Payment Report delayed until the rebuttal period is over. • If a hearing has been requested, preparation of the Improper Payment Report should be delayed until all appeals have been exhausted and a final decision has been issued on the eligibility factor.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 41 Effective Month: March 2019 Calculating Overpayments Overpayments may result when a recipient is found ineligible or eligible for reduced benefits or a different amount of Medicaid Income. In calculating the overpayment, the specialist will: • Determine the action which would have been taken at the time had the correct information been known to the agency or had the agency taken timely action. • Determine the effective date action would have been taken had the correct information been known to the agency. o For an unreported change, determine the earliest date the agency can substantiate that the recipient was aware of the change. The effective date of the change will be used if the agency cannot document an earlier date. Then allow time for the change to have been reported by the individual (10 days) and acted on by the agency (10 days). Then consider the 15-day adverse action notice or timely notice requirement, as applicable, in determining the beginning month of the overpayment. Example: On August 25th, the RO received verification a CHIP recipient became covered by other full health insurance effective May 1st. Eligibility is terminated effective September 30th. The beginning month of the CHIP overpayment is July (allowing the 10/10/15 day rule) and the improper payment period runs through September. Example: An ongoing recipient failed to report a new marriage which occurred on May 10th. The marriage was reported on August 9th. The spouse’s income causes ineligibility, and the case was closed September 30th. The DOM-354 must be submitted in September for the period July through September using the 10/10/15 rule for determining the beginning date of the improper payment period. o When dealing with information withheld or improperly reported at application, the first benefit month will be the first month of the

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 42 Effective Month: July 2025 overpayment. Do not apply the 10/10/15 day rule for improper payments that begin with the month of application. Example: A Healthier MS applicant is approved effective May 1. It is subsequently determined on November 12th he had failed to report resources exceeding the limit at time of application. The case is closed effective November 30th. The beginning month of the Medicaid overpayment is May, and the improper payment period runs through November. DOM-354 must be submitted in December, the month after the month of discovery of the improper payment. Example: An applicant fails to report a spouse with income living in the household when applying on January 10th. The case was approved effective January 1st. The unreported marriage and spouse living in the home was discovered by the RO in August and the case is closed September 30th. The Improper Payment period is January through September. DOM-354 must be submitted in September. o If a change was reported timely, but the agency failed to act on the reported change, the first month of the overpayment will be the effective month the regional office should have made the change. Allow 10 days for the specialist to process the change and 15 days for the advance notice period. o A child under age 19 is entitled to 12-months continuous eligibility provided the approval of eligibility was correct at the time of application or renewal. The continuous eligibility period does not apply to a child approved in error at application or at renewal. For instance, if health insurance coverage is not reported on the MAGI application for a child approved in CHIP, any months the child was on CHIP with insurance are improper payment months. • Use appropriate income and resource levels for the time period in question. o For cases with unreported resources or income, obtain verification and re-budget using the verified resources or income received during the period in question.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 43 o If multiple reportable changes occurred, re-budget each change in the order in which it occurred. • Always evaluate eligibility for Extended Medicaid before establishing an overpayment for a family whose parent/caretaker becomes ineligible due to earnings or child support (after 01/01/2014, child support is no longer income, but spousal support would apply). • Evaluate each person’s eligibility for other coverage groups. For example, a parent/caretaker may no longer be eligible but the child(ren) in the case may continue to qualify. Submitting the Improper Payment Report Once the specialist completes the Improper Payment Report, the form must be reviewed and signed by a supervisor. The completed report with pertinent information supporting referral of the case for an improper payment is then submitted to the RO Supervisor for final review prior to sending the report to the Office of Eligibility. Processing the Improper Payment Report When the Improper Payment Report and supporting documentation are received in the Office of Eligibility, designated staff will: • Review the report to ensure it is complete and that policy has been properly applied. This process may involve further contact with the regional office for additional information or clarification if supporting documentation is unclear or lacking. • Determine the total improper amount of Medicaid Income or CHIP premiums paid in error. • Approve the report and transmit the Improper Payment Report and attachments to the Third-Party Liability Unit (TPL) for recovery efforts. 100.05.02 CLAIMS AGAINST ESTATES When it is determined a recipient has received benefit to which he was not entitled and the recipient is deceased, the improper payment should be reported immediately. If the Improper Payment Report has already been submitted and the regional office Effective Month: July 2025

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 44 Effective Month: July 2025 learns of the death of the individual, this should be reported to the Office of Eligibility immediately. When the TPL discovers a transfer(s) during the estate recovery process, the case will be referred/sent back to the regional office. The transfer must be developed in the usual manner following transfer policy and procedures. An Improper Payment Report will be completed, if applicable, after the rebuttal process has concluded. 100.06 QUALITY CONTROL A Medicaid Eligibility Quality Control (MEQC) review on a random sample basis is required by federal regulations on all non-SSI Medicaid actions handled by the regional offices. On a monthly basis, cases are selected for review from the MMIS Recipient file using an approved sampling method. The sampled cases are assigned to a Medicaid Investigator who will: • Review the case record, make copies of pertinent material, record information on MEQC forms. • Conduct a field investigation as defined by MEQC policy. • Complete the review and make an eligibility decision based on MEQC findings and federal and state policy. The MEQC supervisor then reviews the investigator’s findings and notifies the regional office of the review outcome. A copy of the MEQC memorandum is also issued to the Bureau Director, Deputy, over the regional office and the Deputy Administrator for Eligibility. Regional Office Responsibilities The Medicaid Regional Office will: • Review the case record upon receipt of a MEQC request to ensure the electronic record is current with all appropriate documents; • Review the case record upon receipt of notice of MEQC findings to determine if there is agreement with the finding.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 45 • When there is a disagreement with the finding, send a memorandum immediately stating the reason for the disagreement and providing any relevant information to the Bureau Director, Deputy, who will review and forward the disagreement to the Office of Eligibility. Appropriate policy staff will complete a final review before the disagreement is provided to the MEQC supervisor for re- consideration. 100.06.01 MEQC DISAGREEMENT RESOLUTION PROCESS The request for reconsideration must be received from the regional office within a 2- week period based on the mailing date of the MEQC findings to the regional office. As indicated, staff in the Office of Eligibility will review the information and if the disagreement is appropriate, will forward it to the MEQC supervisor requesting reconsideration. MEQC will: • Review the regional office’s reconsideration request and make a final decision on the review. • Make corrections on the MEQC worksheets, if necessary. • Provide a written notice of the decision to the regional office. • Make final MEQC findings to CMS within the timeframe and manner required in federal regulations. NOTE: The finding will not be reconsidered if the request for reconsideration is received more than 2 weeks from the mailing date of the original finding to the regional office. 100.06.02 FAILURE TO COOPERATE WITH MEQC If the recipient fails to cooperate with Medicaid Quality Control and the investigator is unable to obtain information needed to complete the review, it will be referred/sent back to the regional office for a redetermination. As part of the redetermination process, the information needed by Quality Control will be requested. If the information is not provided, coverage will be terminated because the agency is unable to determine eligibility. Effective Month: July 2025

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 46 Effective Month: March 2019 100.06.03 CORRECTIVE ACTION A corrective action committee at the Division of Medicaid is responsible for reviewing the overall MEQC findings after the review data has been compiled. If the state error rate exceeds federal tolerance, a corrective action plan must be implemented. The Office of Eligibility is responsible for identifying major error trends and planning, developing and evaluating the short and long-term responsibilities, tasks, and goals of the corrective action plan. Implementation of the plan involves staff at the state and regional levels working together to eliminate or reduce errors and misspent dollars identified through the MEQC process.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 1

Table of Contents 101.01 INTRODUCTION ............................................................................................................. 6 101.02 COVERAGE OF THE CATEGORICALLY NEEDY IN MISSISSIPPI ...................... 7 101.02.01 MANDATORY CATEGORICALLY NEEDY – MAGI RELATED ..................... 8 101.02.02 MANDATORY CATEGORICALLY NEEDY - ABD ......................................... 10 101.02.03 MANDATORY CATEGORICALLY NEEDY – SPECIAL GROUPS .............. 12 101.02.04 OPTIONAL CATEGORICALLY NEEDY – MAGI-RELATED ........................ 13 101.02.05 OPTIONAL CATEGORICALLY NEEDY – ABD .............................................. 15 101.03 HOW TO APPLY .......................................................................................................... 19 101.03.01 APPLICANT .......................................................................................................... 19 101.03.01A DECEASED APPLICANTS .......................................................................... 19 101.03.01B NON-APPLICANTS ....................................................................................... 20 101.03.02 DOM APPLICATION FORM(S) ......................................................................... 20 101.03.03 SIGNATURE REQUIREMENTS ........................................................................ 21 101.03.04 REPRESENTATIVES AUTHORIZED TO ACT FOR AN APPLICANT ....... 22 101.03.05 WHO CAN FILE THE APPLICATION .......................................................... 24 101.03.06 ACCESS AND ACCOMMODATION IN APPLYING ................................. 25 101.03.07 REASONABLE EFFORTS TO ASSIST ...................................................... 26 101.04 FILING THE APPLICATION ........................................................................................ 28 101.04.01 RIGHT TO APPLY .......................................................................................... 28 101.04.02 REQUEST FOR AN INFORMAL MEDICAID ELIGIBILITY OPINION ....... 29 101.04.03 SUBMITTING AN APPLICATION AND APPLICATION FILE DATE ........... 29 101.04.04 PROTECTED APPLICATION DATES FOR MEDICAID APPLICANTS. 31 101.04.05 APPLICATIONS RECEIVED FROM MS RESIDENTS OUT-OF-STATE

31 101.04.06 OUT-OF-STATE APPLICANTS .................................................................... 32 101.04.07 RESIDENCE CHANGE DURING THE APPLICATION PROCESS ........ 32 101.04.08 WHERE TO FILE THE APPLICATION ....................................................... 32 101.04.09 VOTER REGISTRATION ................................................................................... 36

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 2

101.05 MEDICAID APPLICATIONS FILED THROUGH ANOTHER AGENCY OR ENTITY ......................................................................................................................................... 37 101.05.01 APPLICATIONS FOR SSI APPLICANTS ........................................................ 38 101.05.02 APPLICATIONS FOR FOSTER CHILDREN AND ADOPTION ASSISTANCE CHILDREN CERTIFIED BY THE DEPARTMENT OF CHILD PROTECTION SERVICES (DCPS) ..................................................................................... 39 101.05.03 ACCOUNT TRANSFERS (AT’S) RECEIVED FROM THE FFM .................. 39 101.05.04 APPLICATIONS RECEIVED FROM THE COMMON WEB PORTAL (CWP) ................................................................................................................................................... 40 101.05.05 LOW INCOME SUBSIDY (LIS) APPLICATIONS RECEIVED FROM SSA 41 101.05.06 HOSPITAL PRESUMPTIVE ELIGIBILTY (HPE) ............................................ 42 101.05.07 PRESUMPTIVE ELIGIBILITY FOR PREGNANT WOMEN (PEP) ............... 43 101.06 INTERVIEWS WITH DOM ........................................................................................... 44 101.06.01 INTERVIEW DISCUSSION............................................................................... 45 101.06.02 CONCLUDING THE INTERVIEW ................................................................... 49 101.07 STANDARDS OF PROMPTNESS ............................................................................. 49 101.07.01 REGIONAL OFFICE RESPONSIBILITIES ................................................. 49 101.07.02 EXCEPTIONS TO TIMELY PROCESSING ............................................... 50 101.07.03 ABD STANDARDS OF PROMPTNESS ..................................................... 50 101.07.04 MAGI-RELATED STANDARD OF PROMPTNESS .................................. 50 101.08 PROCESSING APPLICATIONS ................................................................................. 51 101.08.01 MAKING AN ELIGIBILITY DECISION ......................................................... 51 101.08.02 USE OF COLLATERAL CONTACTS .......................................................... 53 101.08.03 REQUESTING INFORMATION FROM THE APPLICANT ...................... 54 101.08.03A ELECTRONIC DATA SOURCES UTILIZED BY DOM ......................... 55 101.08.03B ELECTRONIC DATA SOURCES UTILIZED BY THE FFM ................. 56 101.08.04 SUPERVISORY REVIEW ............................................................................. 56 101.08.05 APPLICATION ACTIONS .............................................................................. 57 101.08.06 COMPLIANCE AFTER DENIAL ................................................................... 58 101.09 COMBINATION MAGI AND ABD APPLICATIONS ........................................... 58

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 3

101.10 ELIGIBILITY DATES .............................................................................................. 61 101.10.01 BEGINNING DATES OF MEDICAID ELIGIBILITY.................................... 61 101.10.02 BEGINNING DATES OF CHIP ELIGIBILITY ............................................. 62 101.10.03 TERMINATION DATES ................................................................................. 62 101.10.04 RETROACTIVE MEDICAID ELIGIBILITY ................................................... 62 101.10.04A RETROACTIVE MEDICAID FOR ABD APPLICATIONS ........................ 64 101.10.04B RETROACTIVE MEDICAID FOR MAGI-RELATED APPLICATIONS 64 101.10.05 RETROACTIVE MEDICAID FOR DECEASED APPLICANTS ................ 64 101.10.06 RETROACTIVE MEDICAID FOR SSI ELIGIBLES AND FILLING IN GAPS ................................................................................................................................................... 65 101.11 NOTIFICATION ....................................................................................................... 65 101.11.01 ADVANCE NOTICE ............................................................................................. 66 101.11.02 EXCEPTIONS TO ADVANCE NOTICE ........................................................... 66 101.12 PROCESSING DOM EMPLOYEES/FAMILY MEMBERS CASES ..................... 68 101.13 SERVICE DELIVERY SYSTEMS......................................................................... 69 101.14 CONTINUOUS ELIGIBILITY FOR CHILDREN .................................................. 71 101.14.01 EARLY TERMINATION REASONS FOR CHILDREN ............................. 71 101.14.02 DEEMED ELIGIBLE INFANTS .................................................................... 73 101.14.03 ADULTS ........................................................................................................... 74 101.15 THE REDETERMINATION OR RENEWAL PROCESS ................................... 74 101.15.01 REGULAR REDETERMINATIONS OR RENEWALS – MAGI & ABD ... 74 101.15.01A FREQUENCY OF REVIEWS .................................................................... 75 101.15.01B PROCESSING CHILDREN CURRENTLY DUE FOR REVIEW......... 75 101.15.01C PROCESSING CHILDREN NOT CURRENTLY DUE FOR REVIEW 76 101.15.01D PROCESSING AN APPLICATION AND A REVIEW ............................... 77 101.15.02 ASSIGNMENT OF REVIEW DUE DATES ................................................. 78 101.15.03 ADMINISTRATIVE EX PARTE RENEWALS ............................................. 79 101.15.04 PRE-POPULATED RENEWALS ....................................................................... 82

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 4

101.15.05 RETURNED MAIL FROM REDETERMINATIONS ........................................ 84 101.15.06 TIMELY PROCESSING ................................................................................. 85 101.15.07 TIMELY AUTHORIZATION .......................................................................... 85 101.15.08 EX PARTE REVIEWS .................................................................................... 86 101.15.09 SSI REVIEWS REQUIRED FOR SSI TERMINATIONS ........................... 89 101.15.10 RECEIPT OF REGULAR REVIEW FORMS .............................................. 90 101.15.11 DISPOSITION OF A REGULAR REVIEW – ABD AND MAGI ................ 91 101.15.11A APPROVAL OF A REGULAR REVIEW ..................................................... 91 101.15.11B REDUCTION OR TERMINATION OF BENEFITS .................................... 91 101.15.12 REQUESTED INFORMATION PROVIDED AFTER CLOSURE ............. 93 101.16 SPECIAL REVIEWS ..................................................................................................... 94 101.16.01 RECIPIENT REPORTING REQUIREMENTS ............................................... 94 101.16.02 CHANGE REPORTING REQUIREMENTS - ABD .................................... 95 101.16.03 CHANGE REPORTING REQUIREMENTS – MAGI PROGRAMS ......... 95 101.16.04 PROCEDURAL CHANGES – ABD and MAGI ................................................ 96 101.16.05 TAKING ACTION ON REPORTED CHANGES .............................................. 97 101.17 REINSTATEMENTS ..................................................................................................... 99 101.17.01 INFORMATION PROVIDED PRIOR TO EFFECTIVE DATE OF CLOSURE ................................................................................................................................................... 99 101.17.02 90-DAY REINSTATEMENT PERIOD FOR MAGI AND ABD RENEWALS ................................................................................................................................................. 100 101.17.02A RENEWAL CLOSURES REQUIRING REINSTATEMENT ................... 100 101.17.02B RENEWAL REINSTATEMENT NOT REQUIRED .................................. 102 101.17.03 CORRECTIVE ACTION .................................................................................... 102 101.17.04 CONTINUATION OF BENEFITS AND HEARING DECISIONS ................. 103 101.17.05 TEMPORARY CASE CLOSURE .................................................................... 103 101.17.06 WHEREABOUTS UNKNOWN ......................................................................... 104 101.18 OTHER CHANGES – ABD PROGRAMS ................................................................ 104 101.18.01 CHANGES IN MEDICAID INCOME ................................................................ 104

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 5

101.18.02 CHANGE TO A REDUCED SERVICE COVERAGE GROUP .................... 107 101.18.03 WOMEN IN HEALTHIER MS WAIVER OR MEDICARE COST- SHARING GROUPS TRANSITIONING TO COE-088 FOR PREGNANCY AND POST- PARTUM ELIGIBILITY ......................................................................................................... 108 101.19 OTHER CHANGES – MAGI PROGRAMS .............................................................. 109 101.19.01 TRANSITIONING THE PREGNANT CHIP CHILD TO MEDICAID COE-088 ................................................................................................................................................. 109 101.19.02 WOMEN IN THE FAMILY PLANNING WAIVER (FPW) TRANSITIONING TO COE-088 FOR PREGNANCY AND POST-PARTUM ELIGIBILITY ....................... 110 101.20 APPLICATION AND REVIEW SUMMARY CHART ............................................... 111

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 6 Effective Month: September 2023 101.01 INTRODUCTION This chapter provides information on coverage of categorically needy individuals in Mississippi and guidelines for processing applications, annual reviews of eligibility, special reviews of eligibility due to reported changes and reinstatements of eligibility for all Medicaid coverage groups and the Children’s Health Insurance Program (CHIP). • Coverage of the categorically needy is either mandatory or optional. Mandatory groups are required by the passage of federal laws and optional groups are authorized by the passage of state laws. • The application process consists of all activities completed during the timely processing period from the time a signed application form is received by the agency until a notice of approval or denial is issued to the applicant. • An annual review or renewal of eligibility is a full review of all variable eligibility factors, conducted at specific intervals, not to exceed 12 months for each recipient, to determine whether or not eligibility continues. Basic information that is not subject to change is not re- verified. • A special review deals with reported changes that occur during a review period. The impact of each reported change must be evaluated to determine when, how and if the change impacts eligibility. • A reinstatement reopens eligibility without requiring a new application or renewal form. Eligibility may or may not be reopened back to the date of closure, depending on the circumstances. Other changes are also addressed in this chapter that are program specific, such as increases in Medicaid Income and transitioning pregnant women from their original source of eligibility to pregnancy related coverage, when necessary.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 7 Effective Month: September 2023 101.02 COVERAGE OF THE CATEGORICALLY NEEDY IN MISSISSIPPI Medicaid programs in each state must provide coverage to specified categories of needy individuals that include: • Children, • Pregnant women, • Parents or caretaker relatives of dependent children, • Aged individuals and • Disabled or blind individuals.

Within these broad categories of coverage, the specific groups covered are either: • Mandatory – meaning federal law required coverage of the category, or • Optional – meaning federal law allows coverage of the category and state law authorizes the coverage.

Coverage for children, pregnant women and parents and caretaker relatives are referred to as MAGI-related coverage due to the application of Modified Adjusted Gross Income (MAGI) standards to these groups. MAGI standards are financial methodologies used to determine eligibility. Income standards for MAGI-related coverage are referred to as MAGI-equivalent standards. Effective January 1, 2014, federal law referred to as the Affordable Care Act or ACA required that net income thresholds in effect prior to the ACA be converted to equivalent MAGI levels to account for income disregards eliminated by the ACA. Coverage of the aged, blind and disabled are referred to as ABD coverage. ABD policy is based on the most closely related cash assistance program, which is the Supplemental Security Income (SSI) program. The ABD program area uses SSI policy rules except in categories that have been allowed to use more liberal methodologies through State Plan approval or in instances where Medicaid regulations implement Medicaid policy that takes precedence over SSI policy. Refer to the Categories of Eligibility (COE) Chart in the Appendix page by the same name for COE designations, sources of eligibility and other identifying information that is pertinent to each group.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 8 Effective Month: September 2023 Certification Responsibilities Medicaid is certified or authorized by the following entities: 1. The Social Security Administration or SSA, 2. The Mississippi Department of Child Protection Services or DCPS, 3. The Mississippi Division of Medicaid or DOM, 4. Qualified Hospitals that certify Hospital Presumptive Eligibility or HPE 5. Qualified Providers that certify Presumptive Eligibility for Pregnant Women or PEP

101.02.01 MANDATORY CATEGORICALLY NEEDY – MAGI RELATED The following are MAGI-related coverage groups that must be covered, as required by federal law: Mandatory Coverage of Parents and Other Caretaker Relatives Coverage is mandatory for parents and other caretaker relatives who have a dependent child or children under the age of eighteen (18) living in the home whose household income is below the applicable limit established by the state for coverage. The limit established by the state is a MAGI-equivalent standard based on household size. The Division of Medicaid certifies eligibility for this group. • Extended Medicaid coverage for twelve (12) months is mandatory for a family whose eligibility is based on family coverage if the family loses Medicaid coverage solely due to increased income from employment or increased hours of employment provided the family received Medicaid in any three (3) or more months during the six (6) month period prior to becoming ineligible, as determined by the Division of Medicaid. Mandatory Coverage of Pregnant Women Coverage is mandatory for pregnant woman whose household income is at or below the income standard established by the state, not to exceed 185% of the federal poverty level converted to a MAGI-equivalent standard. The Division of Medicaid certifies eligibility for this group.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 9 Effective Month: September 2023 • DOM must provide Medicaid for an extended period following termination of pregnancy to women who applied for and were eligible and received Medicaid services on the day that their pregnancy ends. This period extends from the last day of pregnancy through the end of the month in which a 12-month period ends. • Eligibility must be provided regardless of changes in the woman’s financial circumstances that may occur within this extended period. • A review is required at the end of the 12-month period.

Mandatory Coverage of Newborns Coverage is mandatory for infants born to Medicaid eligible mothers. The infant is deemed eligible for one (1) year from the date of birth. This provision applies in instances where the labor and delivery services were furnished prior to the date of application and covered by Medicaid based on retroactive eligibility. The Division of Medicaid is responsible for certifying eligibility for deemed eligible newborns. Coverage is mandatory for infants born to qualified or non-qualified alien mothers who qualify for Medicaid on all factors other than alien status who receive Medicaid based on emergency medical services, provided an application for emergency services is timely filed with the Division of Medicaid.

Mandatory Coverage of Infants and Children under Age 19 Coverage is mandatory for the following age-specific groups of children certified by the Division of Medicaid: • Infants to age 1 in households whose income is at or below 185% of the federal poverty level converted to a MAGI-equivalent standard. • Children age 1 to age 6 whose income is at or below 133% of the federal poverty level converted to a MAGI-equivalent standard. • Children age 6 to age 19 are eligible for Medicaid if household income is at or below 133% of the federal poverty level. This limit is not converted to a MAGI-equivalent because federal law specifies 133% as the maximum limit.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 10 Effective Month: September 2023 Mandatory Coverage of Adoption Assistance and Foster Care Children Coverage is mandatory for children for whom adoption assistance or foster care maintenance payments are made under title IV-E of the Social Security Act, as determined by the Department of Child Protection Services who certifies eligibility for this group of children. Mandatory Coverage of Former Foster Care Children Coverage is mandatory for former foster care children who are under age twenty-six (26) if the child was in foster care and Medicaid upon reaching the age of 18 or prior to age 21 when released from foster care. Continued Medicaid coverage is certified by the Division of Medicaid in coordination with the Department of Child Protection Services.

101.02.02 MANDATORY CATEGORICALLY NEEDY - ABD The following are ABD coverage groups that must be covered, as required by federal law: Mandatory Coverage of SSI Recipients Coverage is mandatory for individuals receiving Supplemental Security Income (SSI) in Mississippi. This includes individuals receiving SSI pending a final determination of blindness or disability, those receiving SSI under an agreement to dispose of resources that exceed the SSI resource limit, and those receiving benefits under section 1619(a) or considered to be receiving SSI under 1619(b) of the Social Security Act. Coverage also includes those who would be eligible for SSI except for an eligibility requirement used in the SSI program that is specifically prohibited under title XIX. Eligibility for SSI is determined by the Social Security Administration. No separate application for Medicaid is required unless the individual needs to apply for retroactive Medicaid for up to three (3) months prior to the month of the SSI application, in which case the individual must apply with the Division of Medicaid for the retroactive period of eligibility. Mandatory Coverage of Certain Former SSI Recipients Certain former SSI recipients qualify for Medicaid to continue once their SSI terminates if the use of specific income disregards allows Medicaid eligibility.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 11 Effective Month: September 2023 Medicaid eligibility is based on SSI income and resource limits. The Division of Medicaid certifies eligibility for all the former SSI groups, as follows: • Cost of Living Individuals – these are former SSI recipients who become ineligible for SSI cash assistance because of a cost-of-living increase in title II benefits received after April 1977. These individuals must be granted Medicaid coverage if the sole reason for the loss of SSI was an increase in RSDI benefits received by the individual and/or his or her financially responsible spouse. • Disabled Adult Children – these are former SSI recipients age 18 or over whose disability onset date was prior to turning age 22. SSI must have been paid at any time after July 1987 and closed when title II benefits from a parent’s record began or increased, whichever caused the SSI to terminate. • Coverage is mandatory for certain disabled widows and widowers who would be eligible for SSI except for receipt of Social Security widow(er) benefits that terminated SSI. The individual must be age 50 through 64 and not eligible for Medicare to be evaluated for coverage under this provision.

Mandatory Coverage of Certain Medicare Cost-Sharing Groups The Division of Medicaid certifies eligibility for all the Medicare cost-sharing groups: • Qualified Medicare Beneficiaries (QMB) must be entitled to Medicare Part A and have income that does not exceed 100% of the federal poverty level. Medical assistance is limited to payment of Medicare cost-sharing expenses that includes premiums, co-insurance and deductible charges. Note: The only exception to the requirement of entitlement to Part A is made for individuals entitled to Medicare Part B-ID. Medicare Part B-ID, implemented January 2023 from the Consolidated Appropriations Act 2021, is solely for coverage of immunosuppressive drugs. Part B-ID may be awarded to individuals who lose Medicare entitlement based on end stage renal disease (ESRD) 36 months following a successful kidney transplant. Individuals are ineligible for Part B-ID if they have full Medicaid coverage that includes coverage for immunosuppressive drugs or other health insurance.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 12 Effective Month: September 2023 • Specified Low-Income Medicare Beneficiaries (SLMB) must be entitled to Medicare Part A and have income greater than 100% of the federal poverty level but less than 120% of the federal poverty level. Medical assistance for this group is limited to payment of Medicare Part B or Medicare Part B-ID premiums. • Qualifying Individuals (QI) must be entitled to Medicare Part A and have income that is at least 120% of the federal poverty level but less than 135% of the federal poverty level. Medical assistance for this group is limited to payment of Medicare Part B or Medicare Part B-ID premiums under a federal allotment of funds. Eligibility for coverage as a QI is dependent on the availability of federal funds. • Payment of the Medicare Part D pharmacy plan premium is applicable to the Medicare cost-sharing groups of QMB, SLMB and QI provided the beneficiary enrolls in a benchmark or $0 premium pharmacy plan. Benchmark plans are subject to change each calendar year based on plans that choose to participate within Mississippi. • Qualified Disabled and Working Individuals must be entitled to Medicare Part A and have income that does not exceed 200% of the federal poverty level whose return-to-work results in the loss of coverage for Medicare. Medical assistance is limited to payment of the Part A premium. 101.02.03 MANDATORY CATEGORICALLY NEEDY – SPECIAL GROUPS

Mandatory Coverage of Certain Aliens for Emergency Services Emergency services, including labor and delivery services, must be provided to aliens who meet all eligibility requirements for Medicaid coverage in any MAGI- related or ABD coverage group except for their alien status who need treatment of an emergency medical condition. Transplant services are prohibited. Coverage is limited to treatment of the emergency condition only. The Division of Medicaid certifies Medicaid coverage for Emergency Services for Aliens. Mandatory Presumptive Eligibility Determined by Qualified Hospitals Qualified hospitals must be allowed to determine presumptive eligibility for individuals eligible for Medicaid in certain Medicaid coverage groups, referred to as Hospital Presumptive Eligibility or HPE. HPE allows qualified hospitals to

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 13 Effective Month: September 2023 immediately enroll patients in Medicaid who are determined eligible for Medicaid by authorized hospital staff. HPE provides temporary Medicaid eligibility but also allows access to continuing Medicaid coverage provided the HPE decision includes filing a full Medicaid application.

Medicaid coverage groups eligible for HPE decisions include children up to age 19, pregnant women, low-income parents or caretaker relative(s), former foster children and certain women with breast or cervical cancer. The Division of Medicaid is responsible for HPE Medicaid in conjunction with qualified hospitals that certify HPE eligibility.

Mandatory Coverage of Refugees Under the Refugee Resettlement Grant Medicaid is provided to certain refugees under a Refugee Resettlement Grant administered by the Department of Child Protection Services (DCPS). Refugees that meet the eligibility requirements for assistance under the grant are eligible for time limited Medicaid. DCPS certifies the eligibility for all qualified refugees that receive assistance and reimburses DOM with funds from the grant for all medical assistance provided by DOM to eligible refugees.

101.02.04 OPTIONAL CATEGORICALLY NEEDY – MAGI-RELATED Optional Coverage of Foster and Adoption Assistance Children The Department of Child Protection Services (DCPS) certifies eligibility for the following optional groups of children who are in the custody of DCPS: • Children under the age of 21 for whom the Department of Child Protection Services (DCPS) assumes full or partial financial responsibility who are in foster homes or private institutions are certified for Medicaid coverage by DCPS if the child’s income is within state established standards, converted to a MAGI-equivalent standard. • Children under age 21 in adoptions subsidized in full or part by DCPS and children in adoption assistance who cannot be placed for adoption without medical assistance due to special needs of the child are eligible for Medicaid regardless of the child’s income, as determined by DCPS.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 14 Effective Month: September 2023

Optional Coverage of the Children’s Health Insurance Program (CHIP) The Division of Medicaid certifies eligibility for the Children’s Health Insurance Program (CHIP). Uninsured children under age 19 whose household income is at or below 200% of the federal poverty level converted to a MAGI-equivalent standard are covered by CHIP, which is a separate health plan. Covered children include: • Infants to age one (1) whose household income is between the MAGI equivalent standards of 185% - 200% of the federal poverty level; • Children age one (1) to age six (6) whose household income is between the MAGI-equivalent income standards of 133% - 200% of the federal poverty level; and, • Children age six (6) to age nineteen (19) whose household income is above 133% of the federal poverty level but below the MAGI-equivalent income standard of 200%.

Optional Presumptive Eligibility for Pregnant Women Determined by Qualified Providers • Qualified providers are allowed to determine presumptive eligibility for individuals eligible for Medicaid in the pregnancy coverage group (COE 88), referred to as Presumptive Eligibility or Pregnant Women or PEP. PEP allows qualified, registered providers to immediately enroll pregnant patients in Medicaid who are determined eligible for Medicaid by authorized provider staff. PEP provides temporary Medicaid eligibility but also allows access to continuing Medicaid coverage provided the PEP decision includes filing a full Medicaid application. • The Medicaid coverage group eligible for PEP decision is limited to pregnant women. The Division of Medicaid is responsible for PEP Medicaid in conjunction with qualified providers that certify PEP eligibility.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 15 Effective Month: September 2023 Optional Waiver Coverage – Family Planning Section 1115 waiver coverage provides family planning and family planning related services to certain individuals who have family income at or below 185% of the federal poverty level converted to a MAGI-equivalent standard of federal poverty level. Waiver eligibility requirements include the following: • Women and men, ages 13 – 44, may qualify for waiver participation. • Waiver participants may not be otherwise eligible for Medicare, Medicaid, CHIP or other health insurance that includes coverage of family planning services. • Individuals who have had surgery to prevent reproduction cannot qualify for waiver participation, • MAGI non-filer household rules are applied to family income, excluding any non-taxable income sources. Applicants under the age of 19 are budgeted as a household of one with parental and other income disregarded. The Division of Medicaid determines eligibility for participation in the Family Planning Waiver. 101.02.05 OPTIONAL CATEGORICALLY NEEDY – ABD Optional Coverage of the Aged, Blind and Disabled Living At-Home The Division of Medicaid certifies eligibility in full or in part for the following groups of optional ABD groups: • Disabled individuals who work more than an established number of hours each month whose net family earned income is at or below 250% of the federal poverty level and whose unearned income is at or below 135% of the federal poverty level. Resource limits and other non-financial factors of eligibility are required. Premiums are payable for households with countable earnings that exceed 150% of the poverty level. • Women who have been screened for breast or cervical cancer under the Centers for Disease Control and Prevention Breast and Cervical Cancer Early Detection Program and need treatment for breast or cervical cancer, including a precancerous condition of the breast or cervix. Coverage is limited to women who are uninsured and are otherwise not eligible for Medicaid under any other mandatory coverage group and

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 16 Effective Month: September 2023 have not attained age 65. The MS State Department of Health is responsible for the screening, diagnosis and financial eligibility decisions; the Division of Medicaid is responsible for the non-financial eligibility decisions and for certifying Medicaid eligibility during the woman’s active treatment.

Optional Coverage of the Aged, Blind and Disabled Considered to be in an Institution • Individuals who would be eligible for cash assistance if not institutionalized. The individual must be in a title XIX nursing facility or hospital and meet income, resource and other non-financial factors of eligibility, as determined by the Division of Medicaid. • Individuals in institutions who are eligible under a special income test, including the use of an Income Trust, if applicable. The individual must be in a title XIX nursing facility or hospital and meet income, resource and other non-financial factors of eligibility, as determined by the Division of Medicaid. • Certain disabled children age 18 or under who are living at home, who would be eligible for Medicaid if in a medical institution and for whom the Division of Medicaid has made a determination as required under section 1902(e)(3)(B) of the Social Security Act. Optional Waiver Coverage of Non-Medicare Aged, Blind and Disabled Individuals Section 1115 waiver coverage is granted to certain non-Medicare entitled individuals who are aged, blind or disabled and have income at or below 135% of the federal poverty level. Coverage under the waiver is subject to an enrollment cap. Resource limits and other factors of eligibility apply, as determined by the Division of Medicaid.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 17 Effective Month: September 2023

Optional 1915 Waiver Coverage under Home & Community Based Services (HCBS) The following is a list of waiver coverage offered by the Division of Medicaid. Eligibility for waiver participation is determined in full or in part by the Division of Medicaid, as noted. Waiver participants receive full Medicaid coverage plus additional waiver services that allow the individual to remain in a private living arrangement rather than a medical institution. 1. Elderly and Disabled (E&D) Waiver – is operated by the Division of Medicaid. This HCBS waiver includes aged or disabled individuals age 21 or older whose level of care has been certified using a preadmission screening tool. The aged or disabled individual must be eligible as SSI or qualify under an income level that is equal to the Medicaid institutional limit. Institutional income and resource limits and rules apply, including the use of an Income Trust to qualify for coverage. A waiver participant may not reside in a nursing facility or personal care home. The Division of Medicaid certifies eligibility for individuals who do not receive SSI.

2. Independent Living (IL) Waiver – is operated jointly by the Division of Medicaid and the MS Department of Rehabilitation Services. Eligibility is limited to individuals age 16 or older who exhibit severe orthopedic and/or neurological impairments. Clinical eligibility for waiver services is determined through a preadmission screening tool. An individual can participate in the IL waiver and be eligible as SSI, a Katie Beckett recipient, a Disabled Adult Child, a Working Disabled recipient or be eligible in a MAGI-related category or adoption assistance or foster child category of eligibility provided clinical waiver criteria is met. If an individual is not eligible in an allowed category, the individual may be determined eligible using institutional income and resource eligibility rules and limits, including the use of an Income Trust to qualify for coverage. The Division of Medicaid certifies eligibility for individuals who do not receive SSI or foster care/adoption assistance Medicaid through Child Protection Services.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 18 Effective Month: September 2023 3. Assisted Living (AL) Waiver – is operated by the Division of Medicaid. This HCBS waiver includes aged, blind or disabled individuals age 21 or over whose level of care has been certified by a preadmission screening tool. The individual must be eligible as SSI or qualify under the Medicaid institutional income limit. Institutional income and resource limits and rules apply, including the use of an Income Trust to qualify for coverage. Participants must reside in AL facilities that are approved to participate in the AL waiver.

4. Traumatic Brain Injury/Spinal Cord Injury (TBI/SCI) Waiver – is operated jointly by the Division of Medicaid and the MS Department of Rehabilitation Services. TBI’s and SCI’s must meet certain conditions specified by the waiver and the extent of the injury must be certified by a physician. An individual can participate in the IL waiver and be eligible as SSI, a Katie Beckett recipient, a Disabled Adult Child, a Working Disabled recipient or be eligible in a MAGI-related category or adoption assistance or foster child category of eligibility provided clinical waiver criteria is met. If an individual is not eligible in an allowed category, the individual may be determined eligible by the Division of Medicaid using institutional income and resource eligibility rules and limits, including the use of an Income Trust to qualify for coverage. The Division of Medicaid certifies eligibility for individuals who do not receive SSI or foster care/adoption assistance Medicaid through Child Protection Services.

5. Intellectual Disabilities/Developmental Disabilities (ID/DD) Waiver – is operated jointly with the MS Department of Mental Health as an alternative to institutionalization in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID). This HCBS waiver carries no age restrictions and includes individuals eligible as SSI, a Katie Beckett recipient, a Disabled Adult Child, a Working Disabled recipient or eligible in a MAGI-related category or adoption assistance or foster child category of eligibility provided clinical waiver criteria is met. If an individual is not eligible in an allowed category, the individual may be determined eligible by the Division of Medicaid using institutional income and resource eligibility rules and limits, including the use of an Income Trust to qualify for coverage. The Division of Medicaid certifies eligibility

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 19 Effective Month: September 2023 for individuals who do not receive SSI or foster care/adoption assistance Medicaid through Child Protection Services. The Division of Medicaid offers 1915(i) State Plan services to individuals with an intellectual and/or developmental disability that need the services offered under 1915(i), specifically; day habilitation services, prevocational services and supported employment services. If a Medicaid recipient in a full services at-home category of eligibility has the clinical qualifications needed, the recipient can qualify for 1915(i) services without being placed on the ID/DD waiver program provided their income does not exceed 150% of the federal poverty level. Individuals enrolled in a Medicare cost-sharing group (QMB, SLMB or QI) or recipients in a full-service COE with income above 150% FPL can qualify for the 1915(i) services only by qualifying for the ID/DD waiver.

101.03 HOW TO APPLY This chapter provides guidelines on the process of applying for eligibility determinations for all coverage groups. 101.03.01 APPLICANT An applicant is someone whose signed application form has been received by the Division of Medicaid (DOM) and is requesting an eligibility determination. An applicant is also someone whose signed application is received by another agency or entity authorized to make Medicaid certifications. An applicant includes someone who applies for coverage in MS through the Federally Facilitated Marketplace (FFM) and has their electronic application information transferred to DOM via a process referred to as an Account Transfer (AT). 101.03.01A DECEASED APPLICANTS An application for Medicaid may be made on behalf of a deceased individual. The application must be filed before the end of the third month following the

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 20 Effective Month: September 2023 date of death for DOM to be able to consider the month of death for coverage, using the rules that apply for retroactive Medicaid. 101.03.01B NON-APPLICANTS This is an individual who is not requesting an eligibility determination for himself or herself but is included in the applicant’s household to determine eligibility for the applicant. 101.03.02 DOM APPLICATION FORM(S) DOM uses three types of application forms to determine eligibility: • For MAGI-related purposes, the Mississippi Application for Health Benefits is the single streamlined application form used to apply for Medicaid and CHIP. Information from this form is also used to refer individuals to the FFM for health coverage if ineligible for health coverage through DOM.For Family Planning purposes, the Application for Family Planning is the streamlined application form used to apply specifically for the Family Planning waiver program coverage. • For ABD purposes, the Application for Mississippi Medicaid Aged, Blind and Disabled Medicaid Programs is used. • The MAGI-related, Family Planning, and ABD applications forms may be a paper version, an electronic version, or an exact facsimile of the appropriate form. • Applications filed for Medicaid coverage through other agencies or entities have their own Medicaid applications, such as CPS, SSI,HPE or PEP. • The application form is a legal document, completed by the applicant or representative that signifies intent to apply and: o Is the official agency document used to collect information necessary to determine eligibility; o Is the applicant’s formal declaration of financial and other circumstances at the time of application; o Is the applicant’s certification that all information provided is true and correct; o Provides notice to the applicant of his rights and responsibilities; and o May be introduced as evidence in a court of law.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 21 Effective Month: September 2023

101.03.03 SIGNATURE REQUIREMENTS An application form must be signed to be considered a valid application. The signature does not have to be an original signature since applications are allowed to be submitted via means other than on an original paper form; however, a valid signature by someone authorized to apply for Medicaid or CHIP is required. Signed and unsigned applications are treated differently, as specified below. If an applicant is unable to write his/her name, the form may be signed with an “X” mark; however, a witness signature is required. If an applicant is incompetent (adjudged by a court) or incapacitated (due to a physical or mental condition), these conditions require that someone be named to officially represent the applicant, as addressed in “Representatives Authorized to Act for an Applicant.” • Unsigned applications and/or applications signed with a mark that are not witnessed must be returned to the applicant with an explanation of the signature requirements. An unsigned application or an “X” marked application that has not been witnessed is not valid. • Applications that are signed but are incomplete are accepted as valid applications. The Specialist will work with the applicant to complete the information needed. • Applications that are signed by an individual other than a person who is authorized to apply, as specified in “Who Can File” below, are accepted as valid applications. The Specialist must work with the applicant or head of household to obtain an acceptable signature on the submitted application form.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 22 Effective Month: September 2023 101.03.04 REPRESENTATIVES AUTHORIZED TO ACT FOR AN APPLICANT There are three (3) types of representatives allowed to act on behalf of an applicant or recipient in filing an application for health coverage through DOM: 1. Authorized Representative An authorized representative is a person or employee of an organization who is acting responsibly for the applicant with his knowledge and written consent. The MAGI-related application form allows the head of household to designate an authorized representative with no separate written authorization required except in cases where the head of household has a legal representative who is required to act on his/her behalf. ABD applications require the use of a separate authorization form (DOM-302A) for an applicant or recipient to appoint an authorized representative. The authorized representative has knowledge of the applicant’s circumstances and is usually a relative or close friend but may be a designee of an organization if the applicant or recipient permits. The authorized representative must be authorized in writing by the applicant to act on his behalf. The application is filed in the name of the applicant. The authorized representative can provide eligibility information and sign the application form and receive all eligibility notices; however, the applicant or recipient has the right to limit the authority of their authorized representative. The appointment of an authorized representative does not prevent the Division of Medicaid from communicating directly with the applicant or recipient as deemed appropriate. NOTE: In instances where the applicant or recipient designates an authorized representative but places a limit on the receipt of notices by the representative, maintain the authorized representative information in the case record rather than entering the representative information in the system. If representative information is entered into the system, the representative will receive all letters and notices issued by the system. When an organization or other individual assisted with the completion of an application and their primary need is access to case record information rather than function as a case representative, completion of the “Authorization for the Use/Disclosure of Protected Health Information”

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 23 Effective Month: September 2023 form may be more appropriate to allow access to information while the applicant or recipient represents themselves. Contact with the applicant or recipient is needed to make this determination, which must be documented in the case record. 2. Self-Designated Representative

A self-designated representative is a person acting responsibly for an applicant or recipient because the physical or mental condition of the applicant/recipient is such that he cannot authorize anyone to act for him nor can he act for himself. Family members or non-relatives with knowledge of the applicant’s or recipient’s circumstances are allowed to self-designate in writing with the use of a form designed for this purpose (DOM-302B). A representative of an organization or a provider cannot self-designate to represent an applicant or recipient, except in cases where the self-designating individual is an owner, operator or employee of a state-owned long term care healthcare facility. All other individuals representing an organization or provider must become legally appointed to represent an individual for health care decisions, in which case the individual becomes the Legal Representative of the applicant or recipient. A self-designated representative must file an application or review form in the name of the applicant/recipient with the self-designated representative providing required information to determine or re-determine eligibility and sign all eligibility-related forms that are required. The self-designated representative will receive all eligibility notices and letters.

NOTE: A parent or primary caretaker relative is allowed to apply for a child without signing the self-designation form authorizing themselves as a representative. 3. Legal Representative A legal representative is someone who has been legally appointed to act on behalf of an applicant or representative. The legal representative must provide documentation of their legal authorization to act for the applicant or recipient, such as a Power of Attorney document, legal guardianship decree, conservatorship decree, a custody decree or other type of court order, and complete a Legal Representative form (DOM-

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 24 Effective Month: September 2023 302C). All such documents must specify that the legally appointed individual has the right to make health care decisions for the applicant or recipient. If an applicant or recipient is deceased, proof that the individual is the executor or administrator of the applicant’s or recipient’s estate is required if eligibility is needed in the month of death and/or retroactive period. The legally appointed representative will act on behalf of the applicant or recipient in all matters with the Division of Medicaid without limitation.

101.03.05 WHO CAN FILE THE APPLICATION An application can be filed by one of the following individuals, as applicable to the case: • Adult applicants; • Certain minor applicants, including; o A pregnant minor of any age requesting coverage solely due to pregnancy; or o A married minor living with a spouse; or o A minor living independently; or o A minor living with his/her parents and applying only for the minor’s own children. • The parent who has primary physical custody of a minor child; • Either parent of a minor child when physical custody is equally divided between legal parents; • The caretaker relative with whom a dependent child is living who has primary responsibility for the child’s care. o A caretaker relative is a relative by blood, adoption or marriage with whom the child is living who assumes primary responsibility for the child’s care. o A dependent child is under the age of 18 and deprived of parental support by reason of death, absence from the home or physical or mental incapacity. • An authorized representative designated in writing by the applicant on the MAGI application or on DOM-302A, Authorized Representative Form, for ABD;

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 25 Effective Month: September 2023 • A self-designated representative who signs the appropriate DOM-302B, Self-Designated Representative Form, allowing self-designation. • A legal representative with the authority to make healthcare decisions for the applicant who has completed Form 302C, Legal Representative Form.

An application signed by anyone other than a person described above will be accepted, but a signature of a person authorized to apply must be obtained during the application process. 101.03.06 ACCESS AND ACCOMMODATION IN APPLYING Access to a regional office or out-stationed site should not be a barrier for individuals wishing to apply in person or request assistance with the application process. Each office where Medicaid Specialists are located must be accessible for handicapped persons. If a site is not accessible, make alternate accommodations, including assistance with an alternative method of filing the application. Each application intake site and each telephone application are required to accommodate: • Individuals with limited English proficiency, i.e., individuals who are unable to communicate effectively in any language other than his native language. When interpreter services are needed, use DOM’s language and document translation service to secure the assistance of an interpreter capable of communicating in the applicant’s language to assist in the application process and relate the services offered. This service is available free of charge and is available to applicants and those inquiring about coverage, or services offered through DOM. The individual’s privacy must always be protected during such calls. It is not permissible to require an applicant to provide his/her own interpreter or rely on an accompanying adult or minor child of the applicant to provide interpreter services unless it is an emergency involving imminent threat of safety or welfare of the applicant or recipient or person inquiring, and no qualified interpreter is available. However, if the applicant, recipient or individual inquiring about Medicaid requests an accompanying adult to interpret and the adult agrees and reliance on the adult is appropriate to the circumstances, DOM may allow the adult to provide interpreter services.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 26 Effective Month: September 2023 • Blind applicants by reading forms in their entirety, assist in completion of the forms, explain various program requirements and services offered through the agency and answer any questions the applicant may ask. • Deaf applicants by securing a person proficient in sign language when needed or communicate in writing to relate an explanation of program requirements and services offered through the agency and to answer questions. • Individuals who cannot read and/or write by reading forms in their entirety, assist in completion of the forms, explain various program requirements and services offered through the agency and answer any questions the applicant may ask.

101.03.07 REASONABLE EFFORTS TO ASSIST The Regional and Central Office of DOM is expected to: • Provide orderly surroundings to persons who come to the office; • Provide courteous service to all persons who come to or contact the office; • Provide the appropriate application form to anyone who requests one; • Allow any individual the right to apply for any benefits, regardless of circumstances. This includes allowing a clearly ineligible individual to apply; • Communicate in a clear and courteous manner information regarding programs and services offered through DOM; • Determine as soon as possible if the person asking for help is seeking a type of assistance which the agency offers. If the individual is not requesting a type of assistance offered by the regional office, he should be referred to another community agency or resource to meet his needs, if one is available.

In addition, it is required that Medicaid Specialists make reasonable efforts to assist all applicants to have the applicant’s eligibility determined and/or re- determined. Assistance includes, but is not limited to, the following: • Help with forms completion; • Help with securing a representative, if needed;

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 27 Effective Month: September 2023 • Help in obtaining necessary information from third parties; and • Providing information that will assist the applicant in making informed decisions about Medicaid eligibility. Medicaid program policies are public information. Each applicant has a right to know the policies that will impact his eligibility. MAGI and/or ABD applicants who ask for assistance or are not capable of handling the application process and have no available family member or friend capable of assisting or have representatives who do not act responsibly for a MAGI or ABD applicant require special handling. Otherwise, the application will result in multiple denials that must be avoided if agency intervention is needed to resolve a failure to comply with application or renewal processing. Action needed is as follows: • If the application is for long term care in a nursing facility, the Specialist assigned to the nursing facility should contact the facility to let appropriate staff know that the application cannot proceed because the representative is not cooperating, or the applicant is not capable. If the facility is a state-owned or operated facility, the administrator or his/her designee can act as a self-designated representative if there is no available family member that can become the representative. For privately owned facilities, the administrator has the right to become the legal representative to act for the applicant unless another family member is available. If the administrator is willing to become the legal representative, pend the case until the legal authority can be obtained. If the applicant already has a court-appointed legal representative, the nursing facility (or other available family member) has the right to approach the court to have a non-cooperating legal representative removed and replaced with someone willing to act responsibly. • If the application or review is for an at-home ABD or MAGI-related case, the Specialist must speak with the applicant to determine if there is a family member or close friend or neighbor that would be willing to assist the individual in becoming an authorized representative to secure any needed verifications. • If an applicant (MAGI or ABD, at home or in long term care) already has a legal representative appointed as Power of Attorney but the individual is not cooperating in the application process, the Specialist should discuss this matter with other available family members who may be

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 28 Effective Month: September 2023 willing to secure Power of Attorney. The most recently appointed Power of Attorney with the right to make healthcare decisions for the applicant will be the one with the authority to act for the applicant. • If any of the above situations does not address or remedy a situation where an applicant/recipient is incapable or unable to provide needed information and there is either no representative or there is an irresponsible representative who is not acting in the applicant’s best interest, the Specialist must discuss the situation with their supervisor who should seek assistance from their central office contact. 101.04 FILING THE APPLICATION Individuals inquiring about program eligibility requirements should be informed of their opportunity to apply and informed about the various means of applying. If a hardcopy application is requested, the regional office must provide an application to the individual or mail it, as applicable. If another person or agency refers the name of an individual in need of medical assistance to the regional office, the individual will be contacted, if possible, and the various means of applying explained. Otherwise, an application will be mailed if an address is available. 101.04.01 RIGHT TO APPLY Individuals wishing to file an application must be afforded the opportunity to do so without delay. When an individual inquires about making an application at any regional office, an application form must be provided, and the person offered the opportunity to file that day. The agency must allow an individual or individuals of an applicant’s choice to accompany and assist an applicant or recipient in the application or redetermination process; however, to officially represent the applicant or recipient, an individual must become an authorized, self-designated or legal representative. Refer to 101.03.04 for a discussion of authorized representatives and individuals or organizations needing access to case information, in which case the HIPAA release form may be more appropriate.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 29 Effective Month: September 2023 101.04.02 REQUEST FOR AN INFORMAL MEDICAID ELIGIBILITY OPINION An individual seeking assistance from other social service agencies may be required to obtain a statement from DOM advising that he is not eligible for Medicaid to obtain that agency’s services. If the individual indicates through questioning that none of the categorical requirements would be met, i.e., the person is not aged, blind, disabled, pregnant, under age 19 or part of a family with dependent children, the regional office may provide the individual with a statement that he is not eligible based on the self-declared information. The statement must also explain to the individual that the decision is not an official denial and cannot be appealed. If an official denial notice is required, an application must be filed, and a decision rendered after all eligibility factors have been examined according to policy. The “Request for Unofficial Denial” form is in the Appendix page by the same name and must be used to issue an unofficial denial of eligibility. 101.04.03 SUBMITTING AN APPLICATION AND APPLICATION FILE DATE An application for Medicaid may be filed in any of the following described submission methods. The application file date is the date a valid application form is received by the agency: • In person in any regional office, official out-stationed location or other location outside the regional office where eligibility staff are on official duty, such as a nursing home, hospital or other public facility. The filing date is the date received by the office or other location. • By mail in any regional office - o Applications received by mail which arrive after the end of the month but were postmarked by the last day of the month will be considered to have been received by the regional office on the last day of the month in which they are postmarked. • By fax in any regional office. The filing date is the date received by the agency (central or regional office, whichever office first receives the application). An original signature is not required, • By on-line submission of the application to DOM. The filing date is the date received by the agency (central or regional office). An electronic signature is accepted for applications filed on-line with the agency.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 30 Effective Month: September 2023 • By on-line submission of the application through Common Web Portal. The filing date is the date received by the agency (central or regional office). An electronic signature is accepted for applications filed on-line with the Common Web Portal. • By on-line submission of the application to the Federally Facilitated Marketplace (FFM), which is then transferred to DOM. The filing date is the date the application is received by the FFM. An electronic signature is accepted for applications filed on-line through the FFM. • By telephone via a telephonically recorded application process. By telephone via a telephonically recorded application process. The date of filing is the date the telephonic signature is recorded, which should be the date of the telephone interview. Telephone applications are conducted by Medicaid office staff completing the appropriate paper application based on applicant statements that are recorded, including the telephonic signature. A request for a telephonic application received by central office or regional office staff must be coordinated for the interview to be recorded. Upon request, office staff will schedule the telephone interview with the applicant. ABD telephone applications may be accepted by a regional office when circumstances prevent the applicant from applying or being interviewed in any other manner. The date of the telephone interview is the date of filing. The telephonic signature must be recorded. Once a signed and dated application has been received by the agency, it must not be altered by adding, changing or deleting any information. During an interview, an applicant may make changes to the information on an application. If the interview is in-person, the applicant must initial the changes. If the change to information on the application is reported in any other manner, it must be documented in the case record and/or in the case narrative, but not on the application form.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 31 Effective Month: September 2023 101.04.04 PROTECTED APPLICATION DATES FOR MEDICAID APPLICANTS An applicant who applies for Medicaid on any basis is entitled to have eligibility determined under all available coverage groups. Therefore, an individual who files a MAGI-related application does not also have to file an ABD application to be evaluated for potential eligibility in an ABD program and vice versa. Any application received by the regional office must be evaluated across program lines to determine if eligibility exists under any category of Medicaid coverage. For example, a MAGI-related application indicates an applying household member is disabled. If the disabled member of the household is not eligible in a MAGI- related category, an ABD application would be issued as a supplemental form as outlined in 101.09, Combination MAGI and ABD Applications. The MAGI- related application date is the protected filing date. This also includes applications filed through another certifying agency, such as the Social Security Administration (for SSI applicants). If an individual is denied SSI but would qualify in any available Medicaid-only coverage group, the regional office is required to use the SSI application date as the protected filing date for Medicaid benefits. If the individual is eligible for Medicaid-only, the regional office must determine eligibility using the SSI application date as the Medicaid application date. Additional information may be needed to determine eligibility; however, the application date is the SSI application date, and the case must be documented to reflect this. 101.04.05 APPLICATIONS RECEIVED FROM MS RESIDENTS OUT-OF-STATE Applications made for Mississippi residents who are temporarily out of the state may be accepted. Generally, the applicant must return to the state before the application processing period ends. However, the application of someone who is hospitalized in another state and planning to return to Mississippi when discharged may be processed in the usual manner. If the application is approved, the Specialist must review eligibility every three (3) months to determine the individual’s continued intent to reside in MS.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 32 Effective Month: September 2023 101.04.06 OUT-OF-STATE APPLICANTS Applications received from persons residing in another state will be denied and notice mailed to explain that the applicants will need to reapply upon arrival in MS with intent to reside. Persons who are in MS for a temporary purpose, such as a visit, who intend to return to their home out of state are not eligible for Mississippi Medicaid or CHIP. However, applicants must always be given the right to make an application if they wish to do so and receive a decision on their case. 101.04.07 RESIDENCE CHANGE DURING THE APPLICATION PROCESS If the applicant reports moving to another location within the state during the application process, the application must be completed by the first regional office, and if approved, transferred to the new location. If the application is denied, do not transfer the record until the person reapplies in the second location. If the applicant reports moving out of the state during the application process, determine when the move occurred. If otherwise eligible, the applicant may be approved for Medicaid for any requested retroactive months through the month of the move. If the applicant would be CHIP-eligible, determine if eligibility can be established for the month of application or any subsequent month(s) when the applicant lived in MS. NOTE: If only some members of the applicant family are moving from the state, identify the adults and/or children who remain MS residents and handle their ongoing eligibility accordingly. 101.04.08 WHERE TO FILE THE APPLICATION Applications should be filed with or directed to the regional office that serves the applicant’s county of residence. However, applications for individuals living in another RO’s service area must be accepted by any regional office. The regional office must review each application upon receipt and confirm the accuracy of the address if there is a question about the responsible office.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 33 Effective Month: September 2023 The following guidelines should be followed based on the appropriate situation: Application Filed with Correct RO

Date stamp the form if received as a hard copy. Register the application within 48 hours (certain applications are auto registered, such as Account Transfers from the FFM or LIS applications from SSA). Also, scan and upload the application, and any other documents provided, to the appropriate folders in MEDS under case documents. If ABD application received in-person for coverage groups requiring telephonic interview, conduct interview if possible If interview cannot take place, or if application received by mail or electronically, schedule required telephonic interview in writing within 10 calendar days of receipt of application. MAGI applicants applying in person must be offered assistance, if requested. Application Filed with Incorrect RO Accept the application and date stamp; Register the application with the appropriate county and RO within 48 hours of receipt. Also, scan and upload the application and any other documents provided to the appropriate folders in MEDS under case documents. Applications that are auto registered (CWP/FFM/LIS) in the wrong RO should be transferred within 48 hours of receipt. All applications that are not transferred within 7 days or applications for which a 307 has If ABD application received in-person for coverage groups requiring telephonic interview, conduct interview, if possible; offer assistance to MAGI applicants, if requested. Inform the applicant of the RO that will handle the case.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 34 Effective Month: September 2023 already been issued should not be transferred until after the case is completed.

Combination ABD/MAGI Households Combination ABD/MAGI households are defined as cases in which there is both an ABD applicant or recipient living in the same household as MAGI applicants or recipients. ABD and MAGI individuals living in the same household are treated as one case in the system and one record is created, with the person designated as the head of household as the primary case head. The regional office that serves the household’s county of residence is the office responsible for the ABD/MAGI members, regardless of where the application is filed or whether the ABD and MAGI applications are filed at the same time or separately. If an ABD applicant/recipient is institutionalized which causes other ABD/MAGI applicants or recipients to live apart from the institutionalized individual but the household remains bound by relationship (marriage, parent/child), two separate cases are set up in the system; one for the at-home household members and one for the institutionalized member. One case record is established with the person who is the head of household of the ABD institutionalized case as the primary case head. The regional office that serves the county where the nursing facility is located is responsible for both ABD and MAGI cases

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 35 Effective Month: September 2023

Applications Filed with the Federally Facilitated Marketplace (FFM) Applications for MAGI-related Medicaid or CHIP may also be filed on-line with the Federally Facilitated Marketplace or FFM. The FFM is also referred to as the health insurance exchange. An FFM operates in states that choose not to build their own state-operated exchange. The FFM for MS determines eligibility for enrollment in qualified health plans and insurance affordability programs and assists in determining eligibility for Medicaid and CHIP by verifying certain application information through a Data Services Hub. If an individual or family appears to be eligible for Medicaid or CHIP based on Hub verified data, the FFM transfers the electronic account, referred to as an Account Transfer, to MS for completion of the application. • An individual who applies for Medicaid coverage in MS through the FFM has their electronic application information transferred to DOM via a process referred to as an Account Transfer (AT). • AT’s received from the FFM are evaluated for MAGI-related coverage initially but if any household member indicates on the AT that a disability exists or if the individual is aged, that household member is evaluated for ABD coverage. • The “insurance affordability program” referenced above is a term that includes Medicaid, CHIP and coverage in a qualified health plan through the FFM that provides advance payments of a premium tax credit or cost-sharing reductions to qualified individuals. • MAGI-related denials that do not indicate possible ABD eligibility are automatically referred to the FFM for an evaluation of coverage in other insurance affordability programs. Non-Medicare ABD denials are also referred to the FFM for an evaluation of coverage. NOTE: Referrals to the FFM are made upon denial provided the application is not denied for administrative reasons, such as, failure to comply with application requirements, voluntary withdrawal or any other denial due to failure to complete the application process.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 36 Effective Month: September 2023

101.04.09 VOTER REGISTRATION The National Voter Registration Act (NVRA) requires the Division of Medicaid, as a public assistance agency, to offer the opportunity to register to vote or update voter registration to applicants, recipients and adults applying for children at the time of application and at review and whenever an address change is reported. Each regional office must ensure the voter registration form entitled, “Mississippi Mail-In and NVRA Agency Voter Registration Application” form are included with application forms mailed or given out for an applicant to complete, and available during in-person interviews within the office and at out- stationed sites. Voter registration forms are also available on-line for applicants applying online. Voter registration forms must also be offered to individuals applying by telephone. Assistance with completion of the forms must be offered and provided unless assistance is refused. It is not required for the agency to offer voter registration forms/assistance to a representative of an adult. The MAGI-related application form asks if the applicant wants to register to vote. The ABD application form refers the applicant to their worker if the applicant wants to register to vote or update their voter registration information. Responses to these questions are entered into the system for reporting purposes. Voter registration forms completed and returned to the regional office must be logged on the appropriate form and transmitted to the appropriate county Circuit Clerk’s office with 5 business days of receipt. Form received within 5 days of the voter registration deadline must be transmitted daily. The agency offers voter registration training for new employees and existing employees are trained in the specifics of voter registration responsibilities semi- annually.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 37 Effective Month: September 2023

101.05 MEDICAID APPLICATIONS FILED THROUGH ANOTHER AGENCY OR ENTITY Certain applications for Medicaid are filed through other agencies or entities. Currently, these include the following types of applications that are discussed in further detail below. • SSI applications. SSI applicants approved for SSI are automatically eligible for Medicaid with no separate application for Medicaid required unless retroactive Medicaid is needed or there are missing months of SSI eligibility that need to be evaluated for Medicaid-only eligibility to fill in gaps of ineligibility for SSI. In addition, SSI recipients entering long term care in a nursing facility, ICF/IID or PRTF require DOM authorization of a Medicaid per diem payment to the facility. • Children under age 21 who are in the custody of the Department of Child Protection Services (DCPS) and who are certified as Medicaid eligible by the DCPS. Foster children and adoption assistance children determined eligible for Medicaid by DCPS require no separate application. If the individual enters a nursing facility, ICF/IID or PRTF, DOM must authorize the Medicaid per diem payment to the facility. • Applications filed with the FFM and transferred to the Division of Medicaid as Account Transfers (AT’s). Referrals from the FFM require a decision to approve or deny eligibility for Medicaid or CHIP from DOM. • Applications submitted by individuals through the Common Web Portal (CWP) are loaded directly into MEDS to be processed by the Division of Medicaid. Applications from the CWP require a decision to approve or deny eligibility for Medicaid or CHIP from DOM. • LIS (Low-Income Subsidy) applications filed as part of an application for Medicare coverage through the Social Security Administration (SSA). LIS applications are applications whose eligibility is limited to one of the Medicare cost-sharing coverage groups (QMB, SLMB or QI) and require a DOM decision to approve or deny eligibility. • Hospital Presumptive Eligibility (HPE) applications processed by qualified hospitals to certify and place time-limited Medicaid eligibility on file for

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 38 Effective Month: September 2023 individuals qualifying for HPE. HPE eligibility is determined by qualified hospital staff. • Presumptive Eligibility for Pregnant Women (PEP) applications processed by qualified providers/entities to certify and place time-limited Medicaid eligibility on file for individuals qualifying for PEP. PEP eligibility is determined by qualified provider/entity staff.

101.05.01 APPLICATIONS FOR SSI APPLICANTS SSI applicants who file an application with SSA will automatically receive Medicaid for months SSI is approved. A systems-generated notice of Medicaid approval is issued by DOM providing the beginning date of SSI/Medicaid eligibility and informing the SSI recipient that retroactive Medicaid is available. The notice provides the name, address and phone number of the Medicaid Regional Office where a retroactive Medicaid application may be filed. This notice is separate from the SSI notice of approval. SSI applicants who are denied SSI receive a systems-generated notice of Medicaid denial issued by DOM explaining that although SSI/Medicaid is denied, eligibility for Medicaid-only is available. The various ABD coverage groups are described in the notice and so is the availability of retroactive Medicaid. The notice provides the name, address and phone number of the Medicaid Regional Office where a retroactive Medicaid and/or Medicaid-only application may be filed. This notice is separate from the SSI notice of denial. An SSI applicant may apply for SSI and for Medicaid-only with DOM on the same date or for the same time period. When an application is filed for both SSI and for Medicaid-only, a decision is required by DOM on the Medicaid application. It is not appropriate to hold the application while waiting on the SSI decision nor is it appropriate to deny the application because the applicant has an application pending with SSA. If retroactive Medicaid is requested, a Medicaid decision on the retroactive month(s) is required regardless of whether the SSI application is approved or denied. Follow policy outlined in 101.10.06 for SSI Eligibles requesting retroactive Medicaid and/or eligibility for missing month(s) of SSI eligibility.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 39 Effective Month: September 2023 Follow policy outlined in 500.10.01 for SSI Eligibles entering Long Term Care who need the LTC per diem payment authorized by DOM. 101.05.02 APPLICATIONS FOR FOSTER CHILDREN AND ADOPTION ASSISTANCE CHILDREN CERTIFIED BY THE DEPARTMENT OF CHILD PROTECTION SERVICES (DCPS) Children who qualify for Medicaid while in the custody of DCPS are certified as Medicaid-eligible by DCPS, including any retroactive months. However, not all children in the custody of DCPS are eligible for DCPS-related Medicaid, usually because the child has income (or resources) of their own that exceeds the limit(s) allowed by DCPS. If a child is not Medicaid eligible through the DCPS, the county Social Worker or foster parent will apply for Medicaid for the child through the Medicaid Regional Office and the RO will handle as a MAGI-related application, unless the child applies based on disability and ABD Medicaid is requested. Follow policy outlined in 500.10.02 for foster children or adoption assistance children certified as eligible by DCPS entering Long Term Care who need the LTC per diem payment authorized by DOM. 101.05.03 ACCOUNT TRANSFERS (AT’S) RECEIVED FROM THE FFM Individuals who apply for health coverage through the FFM are assessed for Medicaid and CHIP eligibility and health coverage through the FFM. If some or all household members appear to be Medicaid or CHIP eligible, the electronic accounts for those household members are transferred to DOM. If some or all household members are not eligible for Medicaid or CHIP but are eligible for health coverage through the FFM through a participating health insurer, those individuals are enrolled in a Qualified Health Plan (QHP) by the FFM. Individuals who are enrolled in a QHP with income between 100% - 400% of the FPL based on family size can qualify for premium credits to purchase insurance or for cost-sharing subsidies that reduce annual cost-sharing expenses of the insurance purchased through the FFM. Individuals referred for Medicaid or CHIP coverage are first evaluated by the system to determine the following:

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 40 Effective Month: September 2023 • If there is sufficient information on the AT file to identify household members and confirm that applying household members are not currently eligible in any active case, the case is auto registered in the system as a pending application. Sufficient information includes an SSN for all applying. • When an AT is received on a non-qualified non-citizen, determine if individual has received an emergency medical service in the application month or prior three months. The FFM assesses the individual for eligibility but not for an emergency service. • If a household member or entire case is closed in the system, the individual or case will have an application contact opened so that an application can be processed for the applying household members. • If an AT lacks sufficient identifying information to auto-register an application or redetermination contact, the AT defaults to a pdf document on Report RJ564. This report is used by the regional office to register the application in the system and is loaded into the electronic record in MEDS.

The regional office assigned the AT will complete the application in the same manner as an application received by DOM.

101.05.04 APPLICATIONS RECEIVED FROM THE COMMON WEB PORTAL (CWP) The Common Web Portal is a common application form shared with DHS. An individual can apply for SNAP, TANF, and/or Medicaid. Applications filed through the Common Web Portal for health benefits are assessed for Medicaid and CHIP eligibility. If a CWP application lacks sufficient information to auto- register an application or redetermination contact, the CWP form defaults to a pdf document on Report RJ568. This report is used by the regional office to register the application and is loaded into the electronic record in MEDS.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 41 Effective Month: September 2023 101.05.05 LOW INCOME SUBSIDY (LIS) APPLICATIONS RECEIVED FROM SSA For individuals who apply for the Low-Income Subsidy (LIS) with the Social Security Administration (SSA), the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) requires SSA to forward an electronic application to the state Medicaid agency to determine if the individual is eligible in a Medicare Savings Program (referred to by DOM as Medicare Cost-Sharing programs, consisting of QMB, SLMB and QI). An individual indicates their desire to apply for eligibility to be determined under the Medicare cost-sharing programs when applying for Medicare and/or Social Security benefits and checking “yes” to the question that asks about applying for “Extra Help” in paying for Medicare expenses. Electronic applications are received daily from SSA. When the electronic application is received by DOM, the following occurs: • The system checks the recipient file to determine if the individual is currently eligible for Medicaid. If the individual is eligible, the LIS application is placed on a report in Reports On-Line that indicates the LIS application was not registered because the individual was eligible for Medicaid. • If the individual is not currently eligible, the system registers a pending LIS application. • Each regional office must complete their assigned LIS applications by first reviewing the information submitted by SSA on the LIS file. Accept the attested information on the LIS application without further verification and approve the applicant unless: o the income attested on the application is over the income limit; or o the worker is aware of information that is not compatible with the attestation. • If additional information is needed to make a decision on income eligibility, issue applicable Request(s) for Information to secure the needed verification to approve or deny the LIS application.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 42 Effective Month: September 2023 101.05.06 HOSPITAL PRESUMPTIVE ELIGIBILTY (HPE) Qualified hospitals are allowed to make presumptive eligibility decisions prior to a formal determination of Medicaid eligibility by the Division of Medicaid. A qualified hospital is one that participates as a Medicaid provider, has executed required HPE formal agreements with DOM and agrees to make HPE decisions according to state policies provided to authorized hospital staff. HPE is time- limited Medicaid eligibility for certain children, pregnant women, parents or caretakers presumed to be eligible for Medicaid. DOM provides qualified hospitals with the HPE application form and model notices to use to establish HPE. The hospital must provide written notice to the HPE applicant regarding their eligibility for HPE and assist the HPE applicant in completing and submitting the full application for Medicaid before the end of the HPE period. The Division of Medicaid provides training and training material to hospital staff assigned to HPE. These individuals are required to pass a knowledge test before becoming certified to authorize HPE decisions. In addition, DOM provides the HPE staff with HPE applications and notices for use in HPE decisions. HPE approvals must be transmitted by the qualified hospital to DOM central office staff assigned to HPE within 5 days after the approval decision. DOM assigns a Medicaid ID and places HPE on file. The begin date of HPE is the day the hospital approves HPE. The end date of HPE is either the last day of the month following the month the HPE period begins, or the day DOM makes the final decision on the full application, which could either lengthen or shorten the HPE period. If a full Medicaid application is submitted to DOM following the HPE decision, the application is auto assigned to the appropriate regional office, but the application is completed by the central office staff member assigned to HPE. If the application is approved, the regional office is responsible for the case after approval, i.e., at the time of the first renewal or reported change. If the full application is denied, identifying information remains on record with the office in the event the individual reapplies.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 43 Effective Month: September 2023 101.05.07 PRESUMPTIVE ELIGIBILITY FOR PREGNANT WOMEN (PEP) Qualified providers/entities are allowed to make presumptive eligibility decisions prior to a formal determination of Medicaid eligibility by the Division of Medicaid. A qualified provider/entity is one that participates as a Medicaid provider, has executed required PEP formal agreements with DOM and agrees to make PEP decisions according to state policies provided to authorized entity staff. PEP is time-limited Medicaid eligibility for pregnant women presumed to be eligible for Medicaid. DOM provides qualified providers/entities with the PEP application form and model notices to use to establish PEP. The provider/entity must provide written notice to the PEP applicant regarding their eligibility for PEP and assist the PEP applicant in completing and submitting the full application for Medicaid before the end of the PEP period. The Division of Medicaid provides training and training material to provider/entity staff assigned to PEP. These individuals are required to pass a knowledge test before becoming certified to authorize PEP decisions. In addition, DOM provides the PEP staff with PEP applications and notices for use in PEP decisions. PEP approvals must be transmitted by the qualified provider/entity to DOM central office staff assigned to PEP within 5 days after the approval decision. DOM assigns a Medicaid ID and places PEP on file. The begin date of PEP is the day the provider/entity approves PEP. The end date of PEP is either the last day of the month following the month the PEP period begins, or the day DOM makes the final decision on the full application, which could either lengthen or shorten the PEP period. If a full Medicaid application is submitted to DOM following the PEP decision, the application is completed by the central office staff member assigned to PEP. If the full application is approved, the regional office is responsible for the case after approval, i.e., at the time of the first renewal or reported change. If the full application is denied, identifying information remains on record with the office in the event the individual reapplies.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 44 Effective Month: September 2023

101.06 INTERVIEWS WITH DOM Interviews are required for all long-term care (institutional) ABD programs with an asset test. The interview can be conducted in person if the applicant or applicant’s authorized representative applies in person or requests an in-person interview. For all other instances, the interview requirement will be met by a telephone interview. Required interview discussions include provisions specific to ABD that are applicable to the applicant’s case that are listed below. If a specific ABD provision is not discussed during the interview because it was not relevant at the time, contact with the applicant or their representative must be attempted by telephone to discuss the matter. For example: at the time of the interview, it was not known that the applicant needed a Long-Term Care Income Trust in order to qualify. Although a LTC Income Trust document and Help Sheet must be issued to the responsible person via DOM-307, contact with the applicant or representative is also required to explain Income Trust rules. Informing the individual is critical in order for the individual to make an informed choice regarding their eligibility since delaying eligibility is an option as outlined in 304.05.04. Failure to discuss can result in financial hardship and/or unnecessary eligibility issues. Interviews conducted must be documented. Although in-person interviews are not required for any application or renewal, an applicant may request assistance with completing an application either in- person or by telephone. When assistance is requested, include all relevant information described in the “Interview Discussion” described below. Whenever an applicant requests an in-person interview, one will be conducted even if the program does not require an interview.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 45 Effective Month: September 2023 101.06.01 INTERVIEW DISCUSSION In general, during an interview for ABD or MAGI-related applications, the specialist reviews: • Household composition and relationships to explain the individuals who are required to be included in the application and/or budgetary process and those who cannot be included. • The specific programs and services available to the applicant and/or family through the Division of Medicaid, such as non-emergency transportation for individuals eligible for full Medicaid. • Services offered by other agencies with referrals made, as appropriate. The following policy provisions are required for both ABD and MAGI interviews: Provision Required Discussion Points Filing an application The agency must allow individual(s) of the applicant’s choice to accompany and assist the applicant in the application or review process. Coverage groups Eligibility requirements for the coverage group(s) the applicant appears potentially eligible in must be explained. Coverage limited to one source Coverage is limited to only one source of eligibility. If the individual is eligible under another source, that source must terminate before ABD or MAGI-related eligibility begins. Purpose of application The use and purpose of the application, including that the applicant is agreeing to all the rights and responsibilities specified on the application by signing the form. Processing limits The applicable Standards of Promptness (SOP). Conditions of eligibility Discuss critical factors such as age or disability, providing a SSN, citizenship or alien status, assignment of rights, who is authorized to sign the application or act on behalf of the applicant and other factors as applicable as the application is completed or reviewed. QC reviews The Quality Control review process. Computer matching The use of Social Security Numbers in computer matching programs. Appeals Rights to a fair hearing for adverse actions, exceeding SOP, erroneous actions.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 46 Effective Month: September 2023 Provision Required Discussion Points Covered services Available services such as the EPSDT program and the annual physical for adults. Verification of eligibility Verification requirements and methods to be used to establish eligibility, including the use of electronic databases, collateral contacts, and documentary verification. Reporting changes The change reporting requirements. Voter registration Voter registration opportunities. Managed care Enrollment in MississippiCAN for mandatory populations.

The following explanations are specific to ABD institutional applications (LTC and HCBS) and must be addressed as applicable: Provision Required Discussion Points

Estate Recovery Estate recovery as it applies to excluded resources, such as the home or income producing property. Provide copy of Estate Recovery Fact Sheet from DOM website. Income Trust If applicable, provide copy of LTC or HCBS Income Trust document and repayment requirements, either through payment of Medicaid Income or direct payment to DOM of overage or both. If payment is due for month of entry for LTC, explain option to delay Medicaid coverage to following month to avoid payment of amount that is above the institutional limit. Discuss setting up a separate bank account for funding HCBS & if applicable, LTC IT’s. Annuities If applicable, provide copy of ABD handout on annuities and discuss verification and annuity requirements, such as making DOM the beneficiary of the annuity if required. Transfer of Assets Discuss prohibition of transfer of assets within 5-year lookback period and as an ongoing prohibition. Provide the ABD Transfer of Assets handout to all institutional applications (LTC & HCBS). Asset Verification System (AVS) Explain the authorization for financial institutions to disclose financial account information is a condition of eligibility (AVS matching).

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 47 Effective Month: September 2023 Provision Required Discussion Points

Spousal resource & income rules If applicable, discuss spousal impoverishment rules and provide a copy of the Spousal Resource and Income Rules handout. Discuss the 90- day period for transferring assets to the CS subject to the CS limit. Assets over the spousal limit are considered available to the IS. Discuss the spousal income allocation. PAS and 317 forms from NF For LTC applicants, explain the requirement for medical necessity of the NF placement and that forms submitted by the NF will document the level of care requirement. Post-eligibility For LTC applicants, discuss Medicaid Income requirements including income used in the Medicaid Income calculation (counting lump sum payments and averaging income that varies or is infrequent). Explain deductions such as the Personal Needs Allowance, CS and/or other family member deduction, and the allowance of non-covered medical expenses and the need to timely submit any out-of-pocket expenses. Determine if allowable pre-eligibility expenses need to be submitted. Miscellaneous Discuss any other provisions applicable to the case, such as: Medicare covered days, Substantial Home Equity disqualification period, the 30-consecutive day requirement and any other provisions as applicable.

The following explanations are specific to ABD at-home cases: Provision Required Discussion Points Deeming of income & resources from a spouse If applicable, deeming of income and resources from an ineligible (non-applying) spouse to an eligible spouse is required, if living together. Higher couple need standards are then used to determine eligibility (couple FPL or FBR and couple resource limit). Deeming of income & resources from parent to child If applicable, deeming of income and resources from ineligible (non- applying) parent(s) to an eligible child or eligible children is required, if living together. The exception is deeming from a stepparent to a stepchild. The parent(s) income is subject to certain deductions (allocating to ineligible children, a living allowance, etc.) prior to deeming to the child or children. Resources of the parent(s) are also subject to a reduction before deeming. Asset Verification System (AVS) Explain the authorization for financial institutions to disclose financial account information is a condition of eligibility (AVS matching). If accounts cannot be verified electronically, the applicant must provide the needed verification.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 48 Effective Month: September 2023 Verification of income & resources Explain that income & resources will be verified electronically to the extent possible. Income and resources that cannot be verified electronically must be verified through other means. Income and resources of the spouse or parent(s) must also be verified. Deductions from income Explain income deductions for at-home budgeting (student earned income deduction, impairment related work expense(s), excluded income) for at-home budgeting.

The following explanations are specific to MAGI-related applications and must be addressed if the MAGI applicant requests assistance in completing the application: Provision Required Discussion Points Children’s eligibility All possibilities for Medicaid eligibility must be tested before considering CHIP eligibility. Children who qualify for Medicaid cannot be approved for CHIP. The income of a stepparent living in the home with applicant children must be considered toward the children’s eligibility. Parent or Caretaker Eligibility Child Support cooperation requirements and income of an applicant’s spouse must be considered toward the applicant’s eligibility, unless the spouse receives SSI. A spouse can qualify for Medicaid eligibility as a 2-parent household or caretaker/spouse household. Verifications Requested verifications must be provided for each person included in the budgeting process if the verification cannot be obtained through available data sources. Failure to provide information may result in individual or multiple denials, depending on the program or type of verification which is lacking. Income is verified electronically to the extent possible but if not possible, the head of household is responsible for securing the needed verifications. Non-applicants Verification of personal information, income and expenses is not needed for household members who are not included in the budgeting process. Non-countable assets Resources are not considered & non-taxable income is not counted.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 49 Effective Month: September 2023

101.06.02 CONCLUDING THE INTERVIEW At the conclusion of the interview, the applicant or his representative must understand the following: • Additional information the applicant must provide or actions he must take for eligibility to be determined. • Actions the agency must take to determine eligibility. • Notifications required, including a written notice of approval and the issuance of Medicaid or CHIP cards or a denial notice and/or the right to appeal any decision. • Redeterminations, i.e., annual eligibility reviews for children and annual or more frequent reviews, if necessary, for adults. 101.07 STANDARDS OF PROMPTNESS Eligibility must be determined within the appropriate timeframes for the program type as discussed below. If there is a delay in processing, the reason must be clearly documented in the record. 101.07.01 REGIONAL OFFICE RESPONSIBILITIES Each regional office must have controls in place which ensure timely application processing at all staff levels, including sufficient time for supervisory review and corrections. Applications should generally be processed in the order in which received, taking into consideration promptness and delay in receipt of verifications, and in some cases, urgent need. Under no circumstances should an application be approved without the proper verifications and documented eligibility for each applicant.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 50 Effective Month: September 2023

101.07.02 EXCEPTIONS TO TIMELY PROCESSING The agency must determine eligibility within established standards, except in unusual circumstances when a decision cannot be reached because of: • Failure or delay on the part of the applicant. • A disability decision has not been returned by DDS. • Administrative or other emergency delay that could not be controlled by the agency.

Time standards may not be used by the agency as a waiting period before determining eligibility or as a reason to deny eligibility because the agency has not determined eligibility within the time standards.

101.07.03 ABD STANDARDS OF PROMPTNESS Federal rules require that applications be approved or denied, and the applicant notified, within 45 days from the date the application was filed. The processing timeframe is 90 days when a disability determination is required before the eligibility determination can be completed. However, if a separate disability decision is not required, the 45-day standard applies. The applicable standard of promptness, i.e., 45 or 90 days, is applied to an ABD application from the date an application is filed to the date the notice of decision is issued to the applicant. When there is a delay, the reason must be documented in the record. 101.07.04 MAGI-RELATED STANDARD OF PROMPTNESS MAGI-related programs have a 45-day standard of promptness. No more than 45 days may lapse from the date an application is filed to the date the notice of decision is issued to the applicant. Any delays in processing MAGI-related applications must be client-caused or requested. When there is a delay, the reason must be documented in the record.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 51 Effective Month: September 2023 NOTE: For MAGI applications filed with the FFM, the date of application is the date it is filed with the FFM; however, the standard of promptness begins when the application is received by DOM.

101.08 PROCESSING APPLICATIONS Specialists must determine eligibility based on information contained on the application form as well as information secured during the application process. Appropriate DOM forms, along with other legal or official documents which support the eligibility decision must be filed in the correct case documents folder within MEDS. As part of the eligibility process, information provided by the applicant, secured through electronic data bases and obtained from other sources must be verified, documented, and evaluated by the specialist prior to making the eligibility decision. If information provided by or on behalf of an applicant on the application form is consistent with information obtained through electronic data sources, eligibility must be determined based on such information. An applicant must not be required to provide additional verification or documentation unless needed information cannot be obtained electronically or the information obtained electronically is not consistent with information declared on the application or otherwise secured during the application process. 101.08.01 MAKING AN ELIGIBILITY DECISION Eligibility decisions are made using the following: • Verification - Verification is the substantiation, confirmation or authentication of an assertion, a claim or previously submitted information. Verification is obtained using electronic data sources or by information provided by the applicant. The specialist will accept reasonable documentary verification provided by the applicant and will be primarily concerned with how adequately the verification proves the statements on the application form. Only information material to the

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 52 Effective Month: September 2023 applicant’s eligibility is subject to verification, through electronic means or otherwise. Verification provided by an applicant or beneficiary must never be discarded, destroyed, ignored or altered. • Documentation - All cases must be thoroughly documented. Documentation is the written record of all information pertaining to the eligibility decision. Case documentation includes the completed application form, the specialist’s verbal and written contacts with the applicant, information requested and received from electronic data sources, the applicant or third-party sources, such as governmental or nongovernmental agencies, businesses and individuals, and notification of the eligibility decision. When an applicant claims no income or resources, the specialist must fully document the facts provided to substantiate these claims. “Applicant states none” is not sufficient documentation. The case narrative must also show why the statement of the applicant or beneficiary is reasonable and acceptable. NOTE: For MAGI applicants who attest on the application form that one or more household members receive income that does not count (such as SSI, TANF, VA benefits, Workers’ Compensation, Child Support), consider this as documentation of income available to support the family. In other words, the household is not a $0 income household but rather a household sustained by income that does not count. If the application form has no mention of receipt of non- countable income and there is no declared income or resources, the case narrative must contain a reasonable explanation of how the household is meeting basic needs. When action is taken to deny the application because the applicant has not provided the information necessary to determine eligibility within the specified timeframe, documentation in the case narrative must show an appropriate request(s) was issued to the applicant.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 53 Effective Month: September 2023 • Evaluation –Information provided by the applicant or obtained through electronic data sources or third-party sources must be assessed prior to making an eligibility decision. When information is not logical, consistent or reasonable, it must be resolved prior to determining eligibility. When there is conflicting information, the reliability of each source of information must be evaluated and the case narrative should specify which source was accepted and why. The final determination of eligibility is made based on the most reliable source available.

101.08.02 USE OF COLLATERAL CONTACTS If needed verification is not available from an electronic data source, the applicant is generally the source used to supply needed verification. However, at times information may also be obtained directly from third parties.

The specialist has permission to obtain needed verifications based on the signed and dated application form. When it is necessary to request information from banks, insurance companies, or other sources that do not disclose information without a signed release, the DOM-301, Authorization to Release Information, should be used or a copy of signature page of the ABD application form that contains the Release of Information authorization by the applicant. Public records or records available from other agencies may be consulted without the consent of the individual.

Applicants should not be asked to verify information from sources which the agency has access to. This includes electronic data sources and other federal or state benefit information that is available to the agency.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 54 Effective Month: September 2023

101.08.03 REQUESTING INFORMATION FROM THE APPLICANT The applicant has the primary responsibility for providing documentary evidence to verify statements made on the application or to resolve any questionable information when verification from electronic data sources is not available or is inconsistent with applicant provided statements. When additional information is needed, the following action is taken: ABD Applicants MAGI-Related Applicants Issue DOM-307, Request for Information, to take a necessary action to request specific information that must be provided based on the ABD application responses. Request only needed verification and required actions; do not request information that does not apply. Direct contact must be attempted before issuing a written request for information when information from electronic data sources conflicts with information provided on the MAGI application. If a reasonable explanation is provided, document the contact in the case narrative. If direct contact is unsuccessful, document each attempted contact and issue written notice as described below. Issue DOM-309, Second Request for Information, at the end of the DOM-307 request period for any missing information or action addressed on the DOM-307. Do not request any new or additional information on the 309; a new 307/309 is required for information or action not addressed in a previous 307/309.

Issue DOM-307, Request for Information, when needed information is not available from electronic data sources or attempts to contact the applicant by telephone are unsuccessful. List specific information needed to determine eligibility. Request for additional time – for both ABD and MAGI, if the applicant contacts the agency to request additional time, the applicant will have the remainder of the 45-day processing period to submit requested information or take necessary action. (NOTE: for ABD disability applications subject to the 90-day processing period, a denial cannot be issued prior to securing the DDS decision, which may allow additional time for the ABD applicant to provide other needed information.) Explain to the applicant

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 55 Effective Month: September 2023 the latest date that can be allowed to submit information or take necessary action to avoid a denial for failure to provide requested information. Assist the applicant as needed or requested to secure needed information. Failure to provide requested information – if the applicant has not fully complied by the due date on the 307 (for MAGI) or on the 309 (for ABD) and has not requested additional time, the application will be denied due to the failure to provide needed information or take required action. (NOTE: for ABD disability applications subject to the 90-day processing period, a denial cannot be issued prior to securing the DDS decision, which may allow additional time for the ABD applicant to provide other needed information.) Document the denial notice to inform the applicant of the missing verification or action that is the basis for the denial.

101.08.03A ELECTRONIC DATA SOURCES UTILIZED BY DOM For MAGI-related applications, all available electronic data sources are utilized and evaluated to attempt an eligibility determination. If information provided on the application is not consistent with electronic data source verification, the head of the household for the MAGI application must be contacted by telephone for a reasonable explanation of any relevant discrepant information. If a reasonable explanation is not provided, paper verification is requested using the DOM-307, Request for Information, as outlined above.

ABD applications utilize the same electronic data sources shown below except MDHS Data History. ABD resource tested applications also use the Fraud and Abuse Module (FAM) for resources. See 303.05 for FAM procedures.

Electronic data sources utilized by the agency include the following: • Social Security Administration – verifies non-financial factors of eligibility such as SSN verification, U.S. citizenship verification, age verification, disability onset date, if appropriate, and financial verification of benefits paid through SSA. • Department of Homeland Security – verifies immigration status of immigrants in possession of immigration or naturalization papers that can be used to match with Homeland Security.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 56 Effective Month: September 2023 • Department of Employment Security – verifies wages reported to the agency as the State Wage Information Collection or SWICA agency. Also verifies Unemployment Compensation benefits paid. • TALX or FDSH – commercial database that verifies wages reported by employers that utilize this service. • EVVE or Electronic Verification of Vital Events – verifies birth and death records for births and deaths in all states that utilize this service. • Office of Child Support Enforcement (through the Department of Human Services) – verifies compliance with child support requirements for adults subject to this provision as a post-eligibility requirement. • PERS or Public Employees Retirement System (in MS) – verifies benefits paid by PERS. • MDHS Data History-provides income, household composition, and eligibility data that the Mississippi Department of Human Services has on file from their SNAP and TANF programs. Income verified by SNAP (but not TANF) can be used to verify income for MAGI.

101.08.03B ELECTRONIC DATA SOURCES UTILIZED BY THE FFM The FFM utilizes electronic data sources such as the Social Security Administration, TALX, and the Department of Homeland Security to determine eligibility for participation in a qualified health plan or potential eligibility for MAGI-related Medicaid or CHIP. Verified information is passed to DOM through the Account Transfer (AT) record along with attested information from the application filed with the FFM. AT records are then matched or are available for matching with DOM utilized data sources. 101.08.04 SUPERVISORY REVIEW Each ABD and MAGI-related eligibility determination must be authorized by a supervisor, who is responsible for the accuracy, completeness and consistency of information contained in the case record. The supervisor is attesting to the validity of the action taken on the case when it is authorized in the system. The exceptions to supervisory review include childless adult denials, the addition of a deemed infant to a case, family planning and pregnant women approvals. Secondary supervisory review of a case processed by designated experienced

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 57 Effective Month: September 2023 staff members may also be waived at agency discretion during times of severe staff shortages, unwinding from public health emergency, or statewide effort to achieve timeliness. 101.08.05 APPLICATION ACTIONS All applications will be subject to one of the following actions: • Approval – When all the eligibility factors are met, the application is approved, and the applicant is notified in writing or electronically of the approval. • Denial – When one or more eligibility factors are not met, the application is denied, and the applicant is notified in writing or electronically of the denial. Adverse action does not apply. NOTE: Death is not an appropriate reason to deny a Medicaid application. If the applicant dies before a final eligibility determination is made, the application process must be continued to completion. • Withdrawal – When the applicant decides to withdraw his request for assistance during the application process, it is not necessary to complete any remaining verification and evaluation. If the applicant is present, the specialist will obtain the request for withdrawal in writing. When the request to withdraw is not made in person, the specialist will document the case to reflect the specifics of the request. The application will be denied, and appropriate notice issued.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 58 Effective Month: September 2023 101.08.06 COMPLIANCE AFTER DENIAL If a MAGI or ABD applicant provides all needed information to complete the application within 90 days following denial, use the denied application form to establish eligibility using the original application date. Reinstate the application in the system using the original application date.

For example, the application is denied on September 12th. If all needed information is provided on or before December 11th, the application can be reinstated.

If, as a result of new information provided, additional information is needed to complete the application, attempt to handle these issues by telephone contact, if possible. If not possible, issue a DOM-307 (and DOM-309 for ABD, if needed) specifying what is needed to comply. Allow 15 days for the information to be returned.

• If requested information is not provided, no further contact with the individual is required unless the information needed is provided during the remainder of the compliance period. Close the reinstatement contact, delete the time period and document the case narrative. • If all information is provided, take action to approve the application if eligible or deny the application for the appropriate reason if ineligible.

101.09 COMBINATION MAGI AND ABD APPLICATIONS Although MAGI and ABD are separate programs, there are common elements that allow an individual to apply in one program but be determined eligible in the other using available information.

The MAGI application asks specific questions at the individual level regarding possible ABD eligibility. These questions ask if the applying household member:

• is disabled, or • has a physical, mental or emotional condition that limits common activities, or

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 59 Effective Month: September 2023 • lives in a medical facility or nursing home.

An affirmative response to any of these questions requires further development as quickly as possible during the MAGI application process to follow up on possible ABD eligibility if it is unlikely that the individual will qualify for MAGI based on application information. For example, an applying household member is over the age of 18 and is not a parent or caretaker of a minor child in the home, or the parent/caretaker has income over the limit for adult coverage, or a disabled child’s family income is over the Medicaid and CHIP limit. In all these situations, if a disability is alleged for an applying MAGI household member, that individual must be allowed the opportunity to apply for ABD in an expeditious manner.

MAGI Application Filed with DOM Indicates Possible ABD Eligibility

To fulfill the requirement for a MAGI applicant to apply for ABD when a MAGI application indicates possible ABD eligibility, do the following:

• Issue the ABD application form (DOM-300) via DOM-307 requesting only the information that is not available as part of the MAGI application process. The types of verification needed to establish ABD eligibility may be:

o Requesting disability information for a DDS decision if disability cannot be established using electronic verification from SSA on the SVES. o Verification of any income not counted for MAGI purposes, such as VA benefits, that will not be verified during the MAGI application process. o Verification of resources for the individual, couple, or parent(s) of a disabled child, which are not considered for MAGI eligibility.

• A signed ABD application form is required to formalize receipt of an ABD application. If a signed (complete or incomplete) ABD application

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 60 Effective Month: September 2023 form is not received, document the MAGI case that there is no further action required regarding ABD follow-up.

• If a signed ABD application form is received but missing required information, obtain the information by using telephone contact when possible or the issuance of DOM-307/309 to obtain missing information.

• Telephone contact with the ABD applicant or representative may be used in this situation to describe the ABD application process and to inform the ABD applicant of any other requirements unique to ABD. These include ownership of resources, requirements to consent to the AVS (Asset Verification System) requirement described on the application form. For any application for long term care or institutional ABD categories of eligibility, a telephone interview is required to explain any applicable long term care provisions such as estate recovery, spousal impoverishment, transfer of assets, Medicaid Income and the Income Trust provision that are not applicable to MAGI eligibility.

If the ABD applicant(s) follow through with the remaining ABD application requirements, such as providing requested information or taking required actions, the ABD application can be processed and approved regardless of the action taken on the MAGI application. If the MAGI and ABD applications are approved, the case becomes a combination ABD/MAGI case in MEDS and is handled accordingly.

MAGI Application Filed with the FFM Indicates Possible ABD Eligibility

For MAGI applications filed with the FFM and referred to DOM as an Account Transfer, the system recognizes any affirmative responses to the questions that indicate a request to apply for ABD Medicaid and issues DOM-304, Non-MAGI Application Letter (located in the Appendix page by the same name). This letter informs the applying household member that additional information will be needed if the applying household member wants to pursue applying for Medicaid based on disability, i.e., resource information and disability information unless

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 61 Effective Month: September 2023 the individual has already been determined disabled by SSA. The letter instructs the individual to sign, date and return the letter to DOM by mail, in person, by fax or email if he/she wants to continue with an application for ABD Medicaid or, if needed, the individual can contact the agency by phone to continue the process.

If an individual signs and returns the “non-MAGI letter” to the agency via any means acceptable for filing an application, an ABD application must be issued to the individual and the steps described above in “MAGI Application Filed with DOM Indicates Possible ABD Eligibility” must be followed for processing the ABD application.

If a signed non-MAGI letter is not returned to the agency, no further action is required. 101.10 ELIGIBILITY DATES The following discussion addresses Medicaid and CHIP beginning dates of eligibility, ending dates of eligibility, and retroactive Medicaid eligibility.

101.10.01 BEGINNING DATES OF MEDICAID ELIGIBILITY Medicaid applicants, including an applicant who dies prior to filing an application or dies prior to completion of the application process, may qualify for Medicaid on one of the following dates:

• The first day of the month of the application, provided all eligibility factors are met for the first day of the month. • The first day of the month after the month of application in which all eligibility factors are met. • The first day of the first, second or third month prior to the month of application when conditions are met for retroactive Medicaid. • The first day of the month following the month of approval for QMB-only (Qualified Medicare Beneficiary) eligibility. There is no retroactive Medicaid possible for a QMB-only. • The Hospital Presumptive Eligibility (HPE) beginning date of eligibility is the date the HPE application is approved by authorized hospital staff.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 62 Effective Month: September 2023 • Presumptive eligibility for pregnant women (PEP) beginning date of eligibility is the date the PEP application is approved by provider/entity staff.

101.10.02 BEGINNING DATES OF CHIP ELIGIBILITY The benefit start date for CHIP is the first day of the month following the month of application, provided all eligibility factors are met. There is no retroactive eligibility for CHIP-eligible children, other than the newborn exception described below. Newborn exception: The start date for a CHIP-eligible newborn may be retroactive to the date of birth if the application is filed within 31 days of birth. The 31-day count for the application to be filed begins the day following the infant’s date of birth.

101.10.03 TERMINATION DATES Eligibility for a Medicaid or CHIP recipient will end on one of the following days of the month, unless otherwise noted:

• The last day of the month in which the client was eligible; or • The death date of the recipient. or • The date the recipient entered a public institution. • Hospital Presumptive Eligibility (HPE) termination dates are either the last day of the month of the HPE period or the day of the month that the full application for Medicaid is denied. • Presumptive Eligibility for Pregnant women (PEP) termination dates are either the last day of the month of the PEP period or the day of the month that the full application for Medicaid is denied.

101.10.04 RETROACTIVE MEDICAID ELIGIBILITY Retroactive Medicaid eligibility may be available to any Medicaid applicant who received medical care prior to applying for Medicaid. Applicants may qualify for

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 63 Effective Month: September 2023 coverage for a 3-month period prior to the month of the application. Retroactive eligibility can cover all 3 months of the prior period or any month(s) in the 3-month period. In addition: • Each applicant must be informed of the availability of retroactive Medicaid coverage. • The applicant’s statement is accepted regarding medical expenses incurred in the retroactive period. • Retroactive Medicaid may also be available to an individual who is added to a case (e.g., child returns home). • The applicant does not have to be eligible in the month of application (or current month) to be eligible for one or more months of retroactive Medicaid. NOTE: Children have continuous eligibility. A child who is eligible only in a retroactive month will receive Medicaid for 12-continuous months beginning with the month eligibility starts. • The applicant or recipient may ask for retroactive Medicaid coverage at any time. • The date of application, rather than the date of the eligibility determination, establishes the beginning of the three-month retroactive period. • There is no provision for retroactive coverage in the Qualified Medicare Beneficiary (QMB) program. QMB eligibility begins the month following the month of authorization. It is not appropriate to place a QMB-only approval into an SLMB or QI-1 category of eligibility to provide retroactive payment of Part B premiums for the retro period. • Hospital Presumptive Eligibility (HPE) has no retroactive coverage. If a full application for Medicaid is filed and approved, retroactive coverage is available for up to 3 months prior to the month the full Medicaid application is filed. In addition, any partial month of eligibility granted under HPE begin date rules will be changed to full month eligibility. • Presumptive eligibility for pregnant women (PEP) has no retroactive coverage. If a full application for Medicaid is filed and approved, retroactive coverage is available for up to 3 months prior to the month the full Medicaid application is filed. In addition, any partial month of

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 64 Effective Month: September 2023 eligibility granted under PEP begin date rules will be changed to full month eligibility.

101.10.04A RETROACTIVE MEDICAID FOR ABD APPLICATIONS Eligibility in a retroactive month cannot be assumed based on current month eligibility. Determine eligibility for each month separately using the eligibility rules in effect for that month, actual income received in each month and actual resources available in each month. NOTE: Annual Cost-of-Living Adjustment (COLA) increases in Federal benefits cannot be used to determine ABD eligibility in any given year until the Federal Poverty Level (FPL) limits have been implemented for that year. Therefore, when determining retroactive or ongoing eligibility for the months of January, February and possibly March, the prior benefit amount must be budgeted, rather than the actual amount. 101.10.04B RETROACTIVE MEDICAID FOR MAGI-RELATED APPLICATIONS Income determined for current eligibility is used for the retroactive period for MAGI-related cases unless there was a change that must be considered for eligibility in the retroactive period. Accept the applicant’s statement regarding income sources and amounts in the retroactive period unless there is some reason to question the accuracy of the statement, such as electronic data source verification is inconsistent with the applicant’s statements or declared information. For purposes of determining Extended Medicaid eligibility, retroactive Medicaid can be used to determine whether an applicant would have been eligible for Medical Assistance (in three of the last six months. 101.10.05 RETROACTIVE MEDICAID FOR DECEASED APPLICANTS An application for retroactive Medicaid coverage may be made on behalf of a deceased person. Retroactive eligibility can cover all 3 months prior to the month of application or any month(s) in the 3-month period if the deceased person is found to be eligible.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 65 Effective Month: September 2023 101.10.06 RETROACTIVE MEDICAID FOR SSI ELIGIBLES AND FILLING IN GAPS Persons eligible for SSI may be eligible for additional months of eligibility beyond the SSI retroactive period. This period of coverage includes the month of application for SSI and any other missing months of eligibility that exist until the month the SSI payment begins. The SSI eligible person must apply for and be determined eligible for ABD coverage for the interim period of missing SSI eligibility.

An application for the interim period of missing SSI eligibility can be filed at any time and may or may not be filed in conjunction with an application for SSI retroactive Medicaid. However, if an application for retroactive Medicaid was filed and either approved or denied within 90-days of a request to fill in missing month(s) of SSI eligibility, reinstate the prior application using current verification needed to determine eligibility for any missing month(s). The reinstatement is only for the purpose of using the previous application. Eligibility is approved only for the missing month(s) provided the SSI individual is eligible in the missing month(s). 101.11 NOTIFICATION The recipient and, when applicable, the medical facility must be notified in writing or electronically of the action taken on an application or an active case when eligibility or benefit level is affected by a change either at the time of a full review or as a result of a reported change prompting a special review. Notices are generated by the system based on the type of contact and the results of the eligibility determination. NOTE: It is the specialist’s responsibility to review and, if needed, correct notices in the system before they are mailed to the recipient. If a manual notice is required for the recipient, refer to instructions for the DOM-305, Notice of Action, or DOM-306, Notice of Adverse Action. When a manual notice must be issued to a facility, DOM-317, Exchange of Information Between Long Term Care Facility and Medicaid Regional Office, is used.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 66 Effective Month: September 2023 101.11.01 ADVANCE NOTICE Federal regulations require issuance of a notice of adverse action 10 days before the effective date of an action to reduce or terminate benefits. However, federal regulations also require that for continuation of benefits to apply when requesting a hearing, the 10-day advance notice period includes 5-days mailing time. To simplify this requirement, the adverse action deadline is set for the 15th of each month except in February, which is the 13th of the month, to ensure a minimum of 5-days mailing time. During the advance notice period, the recipient is allowed time to fully comply with unmet requirements, provide information or verification that will alter the decision to terminate or reduce benefits, or request a Fair Hearing with continued benefits. If this occurs, the agency must take prompt and appropriate action to reinstate benefits.

101.11.02 EXCEPTIONS TO ADVANCE NOTICE Unless noted, the following actions require notification to the recipient; however, 15-day advance notice is not required. Death When the agency has factual information verifying the death of a recipient, the date of death and verification source must be recorded in the record. A notice is not generated by the system if the termination reason is death. Some acceptable sources to verify the death date are: • SVES, SDX, or EVVE • Report from recipient’s representative or the MAGI Head of Household. • Viewing the death certificate. • Contact with the funeral home or the attending physician. • DOM-317 from the nursing home or contact with the hospital or nursing home where the patient died. • Obituary.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 67 Effective Month: September 2023

Loss of State Residence When the agency establishes that a recipient has moved from the state through information received from the recipient or because another state reports the client has been accepted as a resident for Medicaid in that state, advance notice of closure is not required. Resident of a Public Institution When the agency has established that the recipient has been admitted to a public institution, such as a prison or a state hospital in a non-Title XIX facility, advance notice of termination is not required. Unable to Locate When a recipient’s whereabouts are unknown, the agency must take reasonable efforts to locate the recipient. When agency mail is returned by the post office with no forwarding address and other efforts to locate the recipient are unsuccessful, eligibility will be terminated. However, if the client’s whereabouts subsequently become known during the time the client is eligible for services, the case must be reinstated. Voluntary Request for Closure If the recipient or his designated representative voluntarily requests closure, advance notice is not required. If the request is made in person, the specialist will obtain the request in writing. Otherwise, the specialist will document the case to reflect the specifics of the request. Eligible for Medicaid through Another Source If a MAGI-related or ABD recipient becomes Medicaid-eligible through SSI or foster care, advance notice of termination of benefits authorized through the Medicaid Regional Office is not required.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 68 Effective Month: September 2023

101.12 PROCESSING DOM EMPLOYEES/FAMILY MEMBERS CASES Cases for DOM Office of Eligibility employees, members of their households and immediate family members require special processing and maintenance as follows: • DOM employees must not process their own application, redetermination, or change. They must not directly view, add, remove, replace or edit system information or documents and verifications in the case record. • Further, DOM employees must not process or maintain case(s) that include a member of their household or immediate family. They must not process the application, redetermination or change on these individuals’ cases. They must not directly view, add, remove, replace or edit system information or documents and verifications in the case record. • Immediate family includes the employee’s spouse, ex-spouse, children, stepchildren, ex-stepchildren, children’s spouses and the following relations to the employee or employee’s spouse or ex-spouse: mother, father, stepparent, brother, sister, niece, nephew, grandparent, grandchildren. • Individuals living in the home with the employee are included as immediate family members even if they are not one of the relationships listed above. • DOM Office of Eligibility employees, household members and their immediate family members must be marked as DOM employees in the system to limit system access to all members of the case. • Cases involving family and friends can potentially represent an impropriety or conflict of interest to an employee; therefore, it is the employee’s responsibility to inform the supervisor if the application or case of a family member or friend has been assigned to them. • DOM employees must never directly or indirectly influence or request that another DOM employee process an application for themselves, family members, household members or friends outside of normal assignment and authorization processes. • Individuals who fail to follow the guidelines for processing applications for employees and their family members are subject to disciplinary action.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 69 Effective Month: September 2023 Procedures for Processing Applications of DOM Office of Eligibility employees, Members of Their Household or Immediate Family Members Any application or active case involving a DOM Office of Eligibility employee, household member or immediate family member, as defined above, in any regional office must be processed using the following guidelines:

Application or renewal form and documents must be sent electronically to appointed Central Office staff. Central Office staff only will access the case in MEDS to register, upload, and scan any documents. The employee’s name and relationship to the client must be reported by the RO. Conflict of interest cases or relative cases that are not within the specified degree of relationship listed above should be handled by Regional Office supervisory staff. Cases for DOM Employees who do not work for the Office of Eligibility should be handled by the Regional Office.

Prior to authorizing eligibility, the assigned Central Office staff member will thoroughly review the case and determine the accuracy of the eligibility decision. This may include additional contact with the applicant or others when deemed necessary to make a determination of eligibility. The process described above includes all activity on affected cases at the time of application and review, including special reviews of all such cases. Regional Office staff should inform the Central Office when employees who have an employee or family member case leave the agency. Central Office staff will remove the employee indicator and transfer the case back to the Regional Office. 101.13 SERVICE DELIVERY SYSTEMS The Division of Medicaid operates under two different payment models for services which are fee for service and coordinated care. Once an applicant is approved for Medicaid or CHIP, the individual is enrolled in one of these payment models based on their category of eligibility, age and whether enrollment is mandatory or optional for their category.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 70 Effective Month: September 2023 1. Fee for Service (FFS) – the recipient chooses his/her own provider of service that accepts Medicaid, and the provider is reimbursed by DOM. Fee for Service recipients are entitled to the full array of Mississippi Medicaid State Plan covered services. 2. Coordinated Care – this is a type of managed care whereby certain recipients are either required to enroll or may voluntarily enroll in a Coordinated Care Organization (CCO) and have their medical care managed by the CCO selected. CCO’s connect enrollees to a medical home and provide care management and disease management programs in an effort to provide cost-effective medical services. CCO’s are paid a capitation rate per enrollee and in turn, the CCO pays the medical claims to the Medicaid provider. CCO’s are required to cover all Mississippi Medicaid State Plan covered services unless the contract with the CCO’s states otherwise; however, CCO’s can also offer additional services not covered in the Mississippi State Plan, such as additional physician visits or additional pharmacy benefits.

CHIP enrollees are required to select a CCO. Benefits covered are those required by the DOM CHIP Plan.

For additional information on MSCAN and the mandatory and optional categories of eligibility that can or must enroll in a CCO, refer to the DOM website.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 71 Effective Month: September 2023 101.14 CONTINUOUS ELIGIBILITY FOR CHILDREN When a child under age 19 is approved for Medicaid or CHIP, eligibility continues for 12 months, regardless of changes in family income and other household circumstances. This policy must be applied when determining and re- determining eligibility for a child under age 19, regardless of category (MAGI- related or ABD).

Continuous coverage may also be referred to as a protected period because the child cannot lose eligibility in the assigned category, unless one of a limited number of early termination reasons is met. In addition, the child’s program cannot be changed from Medicaid to CHIP unless the Head of Household voluntarily requests early termination, or the child was approved in error in the current program.

101.14.01 EARLY TERMINATION REASONS FOR CHILDREN The following reasons may shorten the 12-month certification for a child in MAGI-related or ABD programs, as applicable.

• If a child dies, his eligibility must be terminated. • If a child moves out of the state, his eligibility must be terminated. • If a child attains the maximum age for his program and an assessment of continued eligibility indicates the child is not eligible in any other MAGI-related or ABD program, his eligibility must be terminated. Refer to “Ex parte Reviews” later in this chapter for further discussion on assessing eligibility in another program.

o When a child in the Katie Beckett Program will age out of this program, continued eligibility must be assessed in another program. o When a MAGI-related child turning age 19 is pregnant, the child will remain in her current coverage through her post-partum period if the pregnancy information is verified and coded in the system.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 72 Effective Month: September 2023 o At review, an assessment of eligibility in other age-related MAGI categories is automated in the system. For example, an uninsured child turning age 6 in COE-072 during the new 12- month eligibility period will move to either COE-073, 074 or CHIP the month following his/her 6th birthday.

• When the basis of a child’s eligibility is long term care, eligibility must be terminated if the child is discharged from the facility. • If a child becomes eligible for Medicaid through SSI or Foster Care, coverage authorized through the Medicaid Regional Office will be terminated because the child must have only one source of eligibility. (NOTE: If the child becomes eligible in another program authorized by the RO, termination in the current program must be coordinated with the opening in the new program.) • If a child is approved in error, his eligibility must be terminated. • If a child cannot be located after reasonable efforts, his eligibility must be terminated. • If there is a voluntary request for closure, eligibility must be terminated.

In addition to the above termination reasons, CHIP eligibility will also be terminated within the 12-month period for this additional reason:

• The CHIP-eligible child becomes eligible in the 88-program due to pregnancy The child will remain in COE 88 and will be reviewed at the end of the post-partum period. • The CHIP-eligible child becomes eligible for Medicaid.

Other changes for children under age 19 in a child or family-related category of eligibility do not affect the child’s eligibility prior to the end of the 12 months of continuous eligibility.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 73 Effective Month: September 2023 101.14.02 DEEMED ELIGIBLE INFANTS A deemed eligible infant is a child whose mother was eligible for Medicaid in the child’s birth month; however, there is no requirement that the child remain with the mother. The deemed eligible child has continuous Medicaid eligibility for a 13-month period from his birth month through the month of the first birthday unless one of the above early termination reasons is applicable.

Specialists must ensure deemed eligible children are not:

• Terminated prior to completion of the 13th month of Medicaid eligibility; or • Changed from Medicaid to CHIP prior to completion of the 13th month of eligibility, unless the parent or other responsible person voluntarily requests early Medicaid termination.

The deemed child’s eligibility start date should always be his birth month, regardless of the date the agency authorizes eligibility for the child. To terminate eligibility at the end of the deemed period or to make a timely program change from Medicaid to CHIP, the child’s time span begin date should be set for the month following the month of the first birthday.

If the mother is not eligible for Medicaid at the time her child is born, she may apply for Medicaid for herself and her newborn. The application must be filed timely for Medicaid to be retroactive to the birth of the child, i.e., an application must be filed by the end of the 3rd month following the birth month of the child. If all eligibility factors are met, the mother and newborn may be eligible for up to 3 months prior to the month the Medicaid application is filed. If the mother and newborn are determined eligible, the mother will be covered throughout her post-partum period and the newborn will be eligible for 12 continuous months.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 74 Effective Month: September 2023 101.14.03 ADULTS Adults generally have no protected period of eligibility. Changes in income and other circumstances can impact an adult’s eligibility as such changes occur. However, women eligible solely due to pregnancy in any COE program are provided coverage from their first eligible month through the post-partum months regardless of any subsequent changes in income, household composition, etc. This includes women whose eligibility originated in a non- pregnancy related coverage group, such as QMB or Family Planning, who are determined eligible for any COE and transition to any COE for coverage of pregnancy related services for the duration of her pregnancy and post-partum months. In such instances, eligibility must be reviewed for the impact of any changes in circumstances after transitioning back to her original coverage group. 101.15 THE REDETERMINATION OR RENEWAL PROCESS Redetermination is the process of verifying whether a recipient continues to meet the eligibility requirements of a particular program. Redeterminations are classified as either regular or special reviews. A regular review is an annual review of all eligibility factors that are subject to change. A special review is completed when a portion of the case must be re- worked, or case information must be updated because of a change. This chapter addresses the redetermination process. 101.15.01 REGULAR REDETERMINATIONS OR RENEWALS – MAGI & ABD Federal regulations require that the eligibility of every Medicaid and CHIP recipient be reviewed at least every 12 months. Mississippi state law also requires annual reviews. During the regular redetermination process, the recipient’s circumstances are reviewed and each eligibility factor that is subject to change, such as income and/or resources, is re-evaluated. Recipients are not asked to provide information that is not relevant to ongoing eligibility or that already been provided and is not subject to change.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 75 Effective Month: September 2023

101.15.01A FREQUENCY OF REVIEWS A full review must be conducted for all eligible household members (MAGI and ABD) at the earliest 12-month review when case members have different review due dates. When a redetermination is currently due for some but not all case members, a redetermination contact will be set on everyone to attempt to align redetermination dates for the following year and assure one annual review for case members:

• Adults in the case can have their 12-month review period shortened by a change in circumstances that affects adult(s) in the case. The exception is a pregnant adult who is eligible in any COE. • Children that are not due for review require special handling to ensure protection of their 12-months of continuous eligibility, as described in 101.16.01B and 101.16.01C below.

101.15.01B PROCESSING CHILDREN CURRENTLY DUE FOR REVIEW If a child, currently due for review, is determined ineligible or will have a program change from Medicaid to CHIP , the action must be effective at the end of the current 12-month review period. To process the termination or change in the system, the specialist will enter the month following the child’s review due month as the time span begin date.

Example: The child’s review due date is May. The time span begin date is set for June. If timely action is taken by the adverse action deadline in May, a termination will be effective May 31st. If a program change is involved, action must be taken prior to the end of May.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 76 Effective Month: September 2023

101.15.01C PROCESSING CHILDREN NOT CURRENTLY DUE FOR REVIEW Each child must be provided 12 months of continuous eligibility in his eligible category. Prior to the end of the 12-month period, a child cannot be: • Terminated, unless an early termination reason exists, or • Changed from Medicaid to CHIP unless the parent or other authorized person voluntarily requests early closure in the current program, or the original determination was in error.

When reviewing a case with different review due dates and the current review is for the person with the earliest review due date, it is appropriate to set a redetermination contact for all case members; however, the current review and any requests for information must be focused on the case member(s) due for review. Do not request any information on any children with a future review due date. If updated information is provided during the review which results in eligibility for all case members, eligibility can be extended for all members, including children with a future review due date.

If updated information results in ineligibility for any child with a review due date in the future, it is not possible to take action to terminate eligibility prior to the end of the 12-month continuous period. Future termination dates for children not currently due for review are not permitted. Instead, the child or children must be fully reviewed at the end of the 12-month protected period of eligibility. This includes a deemed eligible newborn who is eligible for the first full year of life. Retract eligibility and cancel the redetermination contact for any children affected by a finding of ineligibility. When a program change is involved for a child with a future review date, the change from Medicaid to CHIP cannot be made until the end of the child’s current eligibility period unless the parent or other authorized person consents to early termination in the current program. The change must be reported to the parent or other authorized person by DOM, and consent for the program change must be documented in the case narrative. Changes from CHIP to Medicaid must be acted on.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 77 Effective Month: September 2023 Retract eligibility and cancel the redetermination contact for any children affected by a change from Medicaid to CHIP that has not been approved.

101.15.01D PROCESSING AN APPLICATION AND A REVIEW As previously indicated, when an application is filed to add a new child or adult (MAGI or ABD) to an active case, a review is completed for existing case members at the same time the application for the new member is processed. However, the same policy requirements apply for an application and a review as exists for processing an active case with children not currently due for review:

• Do not request any information on any children with a future review due date. • If updated information is provided for the applicant that results in eligibility for all case members, eligibility can be extended for existing case members, including children with a future review due date. • If updated eligibility results in ineligibility for any child with a future review due date, the child or children must be fully reviewed at the end of their 12-month protected period. • A change from Medicaid to CHIP for a child with a future review date is prohibited unless the parent or other authorized person requests early termination in the current program. • If a finding of ineligibility or a program change results for existing children in the case who are not due for review, retract eligibility and cancel the redetermination contact for the child(ren) with a future review due date.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 78 Effective Month: September 2023

101.15.02 ASSIGNMENT OF REVIEW DUE DATES A regular review must be completed on each recipient at intervals not to exceed 12 months. The system automatically sets a 12-month review at application and redetermination as follows:

APPLICATIONS REVIEWS MAGI applications – a Medicaid application month starts the 12-month count. (Application month + 11 months = review due date.)

For CHIP, the benefit month starts the 12- month count (Month after month of application + 11 months = review due date.) MAGI and ABD review due dates are determined using the time period begin month to start the 12-month count. (Begin month of time period + 11 months = review due date.)

Pregnant Woman’s due date is set to the 12th month of post-partum. 12 months after the end of the pregnancy.

ABD applications – the month the supervisor authorizes eligibility starts the 12-month count. (Supervisor authorization month + 11 = review due date.)

The reviewing supervisor is responsible for ensuring the proper review due date is assigned to each individual and for correcting or adjusting system-assigned dates at authorization when needed. No individual’s review due may be adjusted to exceed 12 months.

Setting Correct Time Spans to Ensure a Child’s 12-Months Continuous Eligibility

Because children (MAGI or ABD) can be added to a case at different times (birth of a child or addition of a child to a case), not everyone within a case may have the same review due date. As stated previously, all children under age 19 (MAGI and ABD) are entitled to 12-months of continuous eligibility.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 79 Effective Month: September 2023 The system sets the review due date based on the beginning month of the time period entered. When completing MAGI and/or ABD redeterminations, the time period must be set as follows: Overdue for Review Set the time span for the month following the month the pre- populated renewal form is received. Children who are approved will have a new review due date 12 months from the time period begin date.

Ineligible children must have a full review at the end of their 12-month protected period.

Current Reviews Set the time span for the month following the earliest redetermination due date for the case. This is the starting point to begin the eligibility assessment. If all children are approved again in the same program, the new review dates will be 12 months from the time period begin month.

101.15.03 ADMINISTRATIVE EX PARTE RENEWALS An administrative ex parte renewal allows eligibility to be renewed based on reliable information contained in the case record and other more current information available to the regional office, such as current data secured from electronic data sources.

• An ex parte review must be attempted on every client due for review. An ex parte review is required annually for SSI-only cases in Long Term Care in COE-005. SSI-only reviews must be completed, or, at a minimum, a redetermination contact must be registered, prior to the scheduled mailing of a pre-populated renewal form for the SSI-only case to prevent a pre-populated renewal form from being issued. For SSI-only reviews, the action needed is to verify the individual remains in the facility, check the SDX for any changes and attempt verification of any resources, such as a patient account or other type(s) of resources available to the SSI recipient.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 80 Effective Month: September 2023 • An ex parte review is processed without contacting or requiring information from the household. If there is no known change in household circumstances and if all reported income types can be verified through available electronic data sources, use current income verification from these sources to renew eligibility. • When electronic data sources indicate a different employer for a household member than the previous year, an ex parte review is still possible if the income results in eligibility for a beneficiary. A change in employer is not a factor in determining eligibility for an ex parte review. • When a client is approved with zero income at application or full review, DOM can complete future reviews ex parte if no data is returned showing countable income at renewal. The client can be renewed ex parte up to 3 times before a full review is needed to get a new attestation of zero income. • Individuals with retirement benefits that are verified at initial application and remain the same for each payment period (month/quarter, etc.) can be renewed ex parte with notation in case narrative that the retirement/pension benefit is stable income and does not change. Individuals who draw retirement benefits that include an annual cost of living adjustment, such as state retirees from other states, are not candidates for ex parte review since their benefit will gradually increase each year. • FAM should be requested as part of the ex parte process for all resource based COEs. Give FAM 5 business days to return. If FAM does not return on a previously verified resource, the worker can use the amount from the last decision when completing the ex parte review. Document in case narrative that FAM did not return, and DOM is assuming no change in assets. Any FAM data returned following completion of the renewal must be documented and addressed if needed. • If all beneficiaries due for a review can be approved in the same or better program using current information verified through electronic data sources, the recipient is notified of the approval. A pre- populated renewal form is not generated for administrative ex parte renewals.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 81 Effective Month: September 2023 • If an ex parte review does not result in an approval in the same or better program, a pre-populated form must be issued to allow the recipient to provide current information. It is possible to move a beneficiary from one Medicaid program to another Medicaid program that provides the same or better coverage based on an administrative ex parte review; however, a child cannot go from Medicaid to CHIP or CHIP to Medicaid. • If some household members due for a review can be renewed ex parte, but other household members due for a review cannot, a prepopulated form must be issued. The household members eligible for an ex parte review must be renewed ex parte when the review form is returned. If the form is not returned, the household members eligible for ex parte review still must be renewed ex parte. • If a recipient reports a change in response to an administrative ex parte renewal approval, document all changes on the “Administrative Review Contact Documentation” form located in the Appendix page by the same name. Attempt verification of a reported change through electronic data sources before requesting information directly from the recipient. • Handle reported changes as a redetermination contact in the system. The appropriate approval or denial notice will be issued based on the outcome of the reported change. Children may not be terminated or switched from Medicaid to CHIP due to a reported change after an ex parte review is completed. • Automated generation of pre-populated review forms take place on a schedule that is published annually and is based on the review due month. Ex parte renewals must be registered as a redetermination contact with a time period pending before the scheduled generation of a pre-populated form. Medicare cost-sharing cases marked “Yes” under “reduced Coverage Adm Review Criteria Met” on the RJ831 and RJ831w will not have an automated prepopulated review form mailed by MEDS. These cases will require a manual prepopulated form to be mailed if an administrative ex parte review cannot be completed.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 82 Effective Month: September 2023 Every regional office must have a process in place to ensure ex parte administrative renewals are attempted as required prior to the scheduled mailing date for the system to issue a pre-populated review form. 101.15.04 PRE-POPULATED RENEWALS If a renewal of eligibility cannot be accomplished by an administrative review, a pre-populated review form is issued to the recipient displaying the information that is available to the agency. The renewal form is an initial request for information. Renewal due dates are included on the form which provides the recipient with time to respond and provide any necessary information specified on the form that is needed to renew eligibility. Renewal includes returning the signed renewal form. Renewal due dates are as follows:

• MAGI-related and ABD renewals have 30-days from the date the renewal form is issued.

The signed form and any paper verifications may be returned to the Division of Medicaid through any of the methods permitted for submission of applications.

MAGI pre-populated renewals are issued with known household composition and demographic data, current income information, tax and dependent status of each known household member and information on any health insurance coverage for household members. There is space on the form for the head of the household to make any needed changes to information reported on the form.

ABD pre-populated renewals are issued with known demographic and income information for each eligible individual or couple. There is space on the form for the individual or couple to make any needed changes to information reported on the form.

• Pre-populated renewal forms (MAGI and ABD) are issued by the system two months in advance of the review. For example, May renewals are mailed out or available on Common Web Portal for beneficiaries with accounts (with electronic notice issued) to recipients in March and are due for completion/return to the Regional Office by April 15th. Reviews

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 83 Effective Month: September 2023 must be completed for adverse action by May 15th or the end of May, as appropriate. • The case must have no open contacts or pending time periods by the published deadline in order for the system to generate a pre-populated renewal form. Any cases that are not in the appropriate status as of the date of mailing will be by-passed by the system making it necessary for the specialist to issue a pre-populated renewal form manually. If a renewal form is issued manually, the specialist must pre-populate the form will all known information required by the renewal form. • If a returned form is incomplete, meaning there is missing information or verification needed, attempt a telephone contact with the head of household to explain what is needed. • If a returned form suggests the client may qualify for a different program (e.g., MAGI reports disability, cost sharing indicates nursing home stay), send a 307 to request any additional information needed to evaluate eligibility for that program • If a renewal form (MAGI or ABD) is not returned by the due date, attempt telephone contact with the recipient as a reminder that the form is due for completion and return to the regional office via mail, in-person or electronically. • When the ABD or MAGI recipient or head of household fails to provide all needed information, action cannot be taken to terminate eligibility due to failure to provide information without first attempting a telephone contact to inform the individual of the information needed and when it must be provided to prevent termination. All efforts to contact the individual must be documented in the case record. • When a renewal form or other requested information is not returned, the worker must attempt to use available electronic data sources to complete a renewal. Any beneficiaries who could be renewed ex parte must be renewed ex parte. Any clients who would change from Medicaid to CHIP, CHIP to Medicaid, or to a lower coverage group must be changed to the new coverage. • Monthly and Weekly Redetermination Due Listings for both ABD and MAGI cases are available in the system to track and monitor cases due for review. Cases that are overdue for review are also part of these reports.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 84 Effective Month: September 2023 • If needed information is provided after the applicable due date for renewal, refer to 101.16.12 “Requested Information Provided After Closure.” 101.15.05 RETURNED MAIL FROM REDETERMINATIONS When an administrative approval notice or a pre-populated review form is returned by the post office, handle as follows:

• If mail is returned with a forwarding address, attempt a telephone contact to confirm the address. If a telephone contact is not successful or possible, update the address and re-route the mail. Document all contact attempts. • If mail is returned without a forwarding address, attempt telephone contact(s) with the household to determine the current address. If all reasonable attempts to contact the household are exhausted and the current address cannot be obtained, terminate eligibility due to “unable to locate.” • If the current address is subsequently obtained for an administrative review approval and it is determined the basis of eligibility in the administrative review was otherwise correct, i.e., no household or income changes, recipients may be reinstated with no loss of benefits if within 90 days of the date of closure. If new income or household information is reported, use the “Administrative Review Contact Documentation” form to collect information. If verification is needed, attempt to obtain it through available electronic data sources before requesting information from the recipient(s). Use a redetermination contact to conclude the review in the system. • If the current address is subsequently obtained for a returned pre- populated form within 90 days of the date of closure, issue the form to the current address and allow 30 days for the form to be returned.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 85 Effective Month: September 2023

101.15.06 TIMELY PROCESSING It is important for redeterminations to be completed in a timely manner to prevent overdue cases. Since a recipient’s eligibility does not expire, benefits continue until the agency completes the review and an eligibility decision is made to either approve or terminate coverage. A review becomes overdue when more than 12 months have passed since the last eligibility determination. It is the responsibility of regional office staff to ensure reviews are processed timely.

When to Begin Processing a Review It is permissible to begin the review process as early as the 10th month of a 12- month eligibility period or no more than 2 months early. However, to ensure timeliness, the review process must begin no later than the month prior to the review month. This means for a case with a review due date of August, the redetermination process may begin as early as June but must begin no later than July. 101.15.07 TIMELY AUTHORIZATION The approval of a Medicaid redetermination is timely if it is authorized by the last day of the month in which the review is due. If Medicaid or CHIP benefits are terminated, the action must be authorized no later than the adverse action deadline in the review month to be effective the following month.

When a redetermination closure is not authorized by the adverse action deadline in the review month, the case or individual is out of certification. However, an improper payment report is not required for the untimely closure. Ineligibility must exist for another reason for an improper payment report to be prepared.

Adverse Action Deadlines The adverse action deadline is the 15th of the month in order to allow 10-days advance notice plus 5 days mailing time. Action must be taken by the adverse action deadline in the review month if coverage is to be terminated at the end of the review month.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 86 Effective Month: September 2023

If Medicaid or CHIP termination action is authorized by the 15th of the month in which the review is due, the termination is effective at the end of the review month. An exception is February when the adverse action deadline is the 13th.

NOTE: Non pregnant adults are not guaranteed 12 months of coverage. If termination is appropriate, the specialist will take action to terminate an adult’s eligibility for the earliest possible month. However, coverage must be terminated no later than the adverse action deadline in the last month of the review period for the redetermination closure to be timely. 101.15.08 EX PARTE REVIEWS Any recipient under review who is losing eligibility in one category of assistance is entitled to have eligibility reviewed and evaluated under any/all available coverage groups. The term “ex parte review” means to review information available to the agency to make a determination of eligibility in another coverage group without requiring the individual to come into the office or file a separate application.

When to Complete an Ex Parte Determination For an ex parte determination to be made, the specialist must be in the process of making a decision on a current application, review or reported change. If the specialist is denying or closing for failure to return information or failure to complete the review process, an ex parte determination is not applicable.

Example: Jane Doe’s CHIP eligibility will terminate because the family reports she is now covered under other health insurance. The specialist must review the record to see if it contains information which indicates the child has potential eligibility under another coverage group. Example: Recipient Tom Smith failed to comply with the annual review requirement and his eligibility must be terminated. The specialist does not complete an ex parte determination.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 87 Effective Month: September 2023

Basis for the Ex Parte Review The decision of whether the recipient is eligible under a different coverage group must be based on information contained in the case record. This may include income, household or personal information in the physical record which indicates the ineligible adult or child has potential eligibility in another coverage group. It also includes information received through electronic matches with other state/federal agencies such as a disability onset date or prior receipt of benefits based on disability.

Obtaining Information to Make the Determination When potential eligibility under another coverage group is indicated, but the specialist does not have sufficient information to make an eligibility determination, the recipient must be allowed a reasonable opportunity to provide necessary information.

Using DOM-307, the specialist will ask the recipient to provide verifications needed to determine eligibility in the new category. If the individual is an ABD recipient potentially eligible in a MAGI category or vice versa, the request will include completion of the appropriate application form to collect required program information. An in-person interview is not conducted in the ex parte review process even for a program that normally requires an interview.

Eligibility Decision If the individual is subsequently determined to be eligible in the new category, the approval must be coordinated with termination in the current program to ensure there is no lapse or duplication in coverage. However, if requested information is not provided or if the information clearly shows that the recipient is not eligible under another category, eligibility in the current program will be terminated with advance notice.

During the advance notice period, the recipient is allowed time to provide all requested information to determine eligibility in the new program, provide information which alters the decision to terminate benefits in the current program or request a hearing with continued benefits. The specialist must take prompt and appropriate action to reinstate benefits when the recipient either

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 88 Effective Month: September 2023 provides all requested information needed to determine eligibility in another category, provides information which changes the termination decision in the current program, or requests a hearing with continued benefits during the advance notice period.

NOTE: When the recipient is determined ineligible in the new category, he does not have to repay the benefits he received while the eligibility determination was in process. However, if benefits are continued pending a fair hearing decision and the outcome is not favorable to the recipient, he is liable for repayment of the cost of services furnished solely because of the continuation of benefit provision.

Requested Information Provided After Closure If the recipient subsequently provides all the information needed to assess eligibility in the new program within 90-days of termination, the case should be handled in accordance with “Requested Information Provided After Closure,” described in 101.15.12. Example: A CHIP review is due in May. On May 10th, the specialist determines the children’s eligibility will terminate because of excess family income. She completes an ex parte review of the case record and notes the SVES response for one child indicates the child has prior SSI eligibility. Since information available to the agency indicates a potential disability for this child, the specialist determines the child must be evaluated for another coverage group before her CHIP eligibility can be terminated. Since the ex parte review does not indicate potential eligibility in any other coverage group for the other children, the specialist completes the closure action for them, leaving eligibility open for the potentially eligible child. She documents the case to support the action. The specialist issues a 307 requesting a completed ABD application form and other information to determine Medicaid eligibility based on disability. The family does not respond to the request. On May 23rd after the 307 request period has expired, a 309, Second Request for Information, is issued. The family subsequently provides the required information. CHIP benefits remain open while the eligibility determination process continues.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 89 Effective Month: September 2023 On August 10th, the child is determined eligible in the Katie Beckett Program. Her CHIP eligibility is terminated effective August 31st and ABD Medicaid eligibility is authorized effective September 1st in the system.

101.15.09 SSI REVIEWS REQUIRED FOR SSI TERMINATIONS The SSI review process is a type of ex parte review. When individuals are terminated from SSI due to income and/or resources, they are systematically issued an SSI Termination Notice and an SSI Review Form, DOM-300B, upon receipt of SDX notification of termination. This form is to be completed and returned to the appropriate regional office if the recipient wants to apply for continued Medicaid coverage and is eligible under one of the coverage groups described in the SSI Termination Notice. A signed form is required. The form may be complete or incomplete. If incomplete, the specialist will take the necessary steps to obtain needed information. NOTE: The SSI Termination Notice advises the individual to complete and return the form to the regional office with 10-days from receipt of the notice; however, allow the form to be returned prior to the date of the SSI closure. SSI/Medicaid closures are effective for the end of current month only if the SSI transaction to close SSI/Medicaid is received by the 10th day of the month; otherwise, the closure is effective at the end of the following month. If the DOM-300B is not received timely, the individual can apply at any time using the full ABD application form. All necessary factors of eligibility must be verified, such as disability, residency, etc. In addition, if other health insurance coverage is indicated on the 300B, TPL information must also be obtained. SSI redeterminations have a 30-day processing standard, unless a DDS determination must be obtained.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 90 Effective Month: September 2023 101.15.10 RECEIPT OF REGULAR REVIEW FORMS MAGI-related and ABD regular reviews may be submitted to a regional office by any of the means allowed for filing an application. Receipt of a redetermination or review form includes pre-populated forms that were issued by the system or manually, SSI review forms, and ABD review forms issued systematically or manually. These forms may be received in any of the following ways:

By mail in any regional office or in the central office. If received in the incorrect RO, forward to the correct RO in the same manner as an application.

By fax. An original signature is not required. In-person in any regional office, out- stationed site or other location where eligibility staff are on official duty. If assistance is requested in completing the renewal form, assistance must be provided on the day the individual comes into the office or other location.

By telephone. Assistance completing the review form must be offered if needed.

The Telephonic signature must be recorded Electronically via email Beneficiaries can upload and submit renewal form via email to the RO. On-line Beneficiaries can utilize the common web portal (CWP) self-service component to complete renewal form and upload needed documents..

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 91 Effective Month: September 2023 101.15.11 DISPOSITION OF A REGULAR REVIEW – ABD AND MAGI ABD and MAGI redeterminations are completed administratively, if possible, or by use of a pre-populated review form that is issued either systematically or manually, as discussed above. When the form is returned and all information subject to change has been evaluated and a decision is reached regarding continuing eligibility, the following actions will be authorized:

101.15.11A APPROVAL OF A REGULAR REVIEW When the ABD recipient/representative or MAGI head of household has complied with all redetermination requirements and provides required verifications, the specialist will review the eligibility criteria; ensure appropriate documentation is filed systematically in the case documents structure and input the data into the system for an eligibility decision. All redeterminations are submitted for supervisory review and authorization. Secondary supervisory review of a case processed by designated experienced staff members may also be waived at agency discretion during times of severe staff shortages, unwinding from public health emergency, or statewide effort to achieve timeliness. When eligibility will continue at the same level, a new review due date is established, and an approval notice issued to the recipient or head of household when benefits are authorized.

101.15.11B REDUCTION OR TERMINATION OF BENEFITS Advance notice of adverse action is required, if the eligibility decision results in termination of benefits for all or some members of the case. During the adverse action period, the recipient or head of household is allowed time to fully comply with unmet redetermination requirements, provide information or verification that will alter the adverse action decision or request a fair hearing with continued benefits.

For MAGI-related cases, adverse action is required in the following situations: • Termination of benefits for one or all members of the household • Change from Medicaid to CHIP • Change from CHIP to Medicaid

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 92 Effective Month: September 2023 • Conversion to a reduced services coverage group For ABD cases, adverse action is required in all the following situations:

• Termination of benefits. • Conversion to a reduced services coverage group. • Termination of a nursing facility per diem payment.

The system is not programmed for the case to remain open during the adverse action period; however, eligibility staff must treat the case as if it is open until the period has ended. During this period if the ABD recipient or MAGI head of household subsequently complies with all redetermination requirements or provides information which changes the negative action, eligibility must be reinstated. If the client requests a hearing, with continued benefits, the case must be promptly reinstated. Specialists must take prompt action on the information provided during the advance notice period. Timely action must be taken to prevent a break in coverage, whether the client takes action within the first few days of the adverse action period or on the final day. ABD Example: The recipient did not provide income verification needed for the May redetermination. The closure is authorized on May 10th and advance notice is mailed to the recipient advising that eligibility will terminate effective May 31st. On May 18th, within the advance notice period, the verification is received in the office. The specialist takes action to process the case as a reinstatement and determines eligibility using the current income. The supervisor then reviews the action and authorizes the eligibility decision. Appropriate notice is issued to the client and there is no break in coverage. MAGI Example: The head of household failed to comply with redetermination requirements for a May redetermination. The case was closed on May 15th effective May 31st. On May 29th partial verification is provided; however, all information needed to process the case is not provided. A reinstatement contact is registered for May 29th. A 307 is issued for the information and 30-day processing is applicable.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews P a g e | 93 Effective Month: September 2023

101.15.12 REQUESTED INFORMATION PROVIDED AFTER CLOSURE When an ABD or MAGI case is closed due to failure to provide information, a reapplication is not required if the following are met:

• The recipient or head of household subsequently provides all information necessary to complete the redetermination; and • The case has been closed for 90-days or less at the time the information is provided. Example: The recipient did not provide income verification needed for the May redetermination. The closure is authorized on May 10th effective May 31st. If the information is furnished by August 31st, eligibility can be determined using the reinstatement process. After August 31st, a reapplication must be filed. NOTE: If a MAGI-related child was not due for review when action was taken to terminate other household members who were due for review, the 90-day provision described above does not apply since any child(ren) not due for review could not have been closed with a future date. Children undergo a full review at the time end of their 12-month protected period. The specialist is responsible for taking action within 48 hours of receipt of the information to register the reinstatement in the system. The case will be processed based on the most recent application and/or renewal form. There is no requirement to obtain an updated signature on the application form. Refer to the Reinstatement policy for a complete discussion of the process required to reinstate eligibility.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page | 94 Effective Month: September 2023 101.16 SPECIAL REVIEWS A special case review is completed when changes occur between regular reviews, which may result in adjustments to eligibility or benefit level. A special case review is not a full review. Instead, the case (or an individual) is evaluated to consider the impact of the changed information. Factors unrelated to the change are not re-verified as part of a special review. Example: A COE-075 adult recipient reports three months after her regular redetermination that she has a part-time job. The children in the case have income from Social Security which was last verified at the regular review. The Social Security income is not subject to re-verification since it is not part of the reported change. A special review of eligibility is required when: • The recipient reports a change in circumstances which could affect eligibility and benefit level. • Information is received from any other source which could affect eligibility and benefit level. • Potential changes in eligibility are indicated by information available to the agency.

The special review process may result in termination of benefits, benefit reduction or adjustments to Medicaid Income. It may also involve procedural changes, i.e., updating or correcting case information with no impact on eligibility or benefits. Special reviews are handled differently, depending on the impact the change may have on eligibility and is discussed below. 101.16.01 RECIPIENT REPORTING REQUIREMENTS Recipients must report required changes within ten days of the date the change becomes known. Changes may be reported in person, by telephone, by mail, through the Common Web Portal, or by fax to the agency. A change is considered reported on the date the report of change is received by the agency. If an individual fails to report timely or the agency fails to take timely

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page | 95 Effective Month: September 2023 action, causing the recipient to receive benefits to which he is not entitled, the specialist will take steps to report an overpayment. 101.16.02 CHANGE REPORTING REQUIREMENTS - ABD The following types of changes must be reported by ABD recipients within 10 days of the date the change becomes known: • Changes in address in or out of state. • Changes in marital status. • Changes in income for the recipient and/or spouse. • Change in any type of policy that would pay for medical services, such as health insurance, indemnity policies, major medical policies, CHAMPUS or legal settlements. • Changes in a recipient’s disability which would affect his Medicaid eligibility. • Changes in living arrangements, such as a long-term care (LTC) recipient entering a hospital or a nursing home, leaving a hospital or a nursing home, moving from one medical facility to another. • Changes in resources, i.e., recipient buys, sells, gives away or receives an asset or any part of an asset. • Changes in health insurance premiums for LTC recipients.

101.16.03 CHANGE REPORTING REQUIREMENTS – MAGI PROGRAMS The following changes must be reported by MAGI-related recipients within 10 days of the date the change becomes known. All MAGI Recipients • Changes in address in or out of state. • Changes in any type of policy that would pay for medical services, such as health insurance, indemnity policies, major medical policies, CHAMPUS or legal settlements.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page | 96 Effective Month: September 2023 COE-075 Adults • Increases in earnings or other income. • Changes in marital status. • Changes in household, such as spouse or parent entering or leaving the home and/or children entering or leaving the home. COE-075 Adults on Extended Medicaid • Termination of employment when new or increased wages caused ineligibility. • Termination of spousal support income when new or increased spousal support caused ineligibility. Pregnant Women • Change in the verified due date, i.e., earlier delivery/termination date or later due date than originally verified. Child Only Cases • Children leaving the home (includes institutionalization, death, foster care, etc.); • Uninsured CHIP child becoming covered by creditable health insurance. • CHIP child becoming pregnant.

101.16.04 PROCEDURAL CHANGES – ABD and MAGI Procedural changes include: • Name corrections or changes. • In-state address corrections or changes. • Change or appointment of a guardian or conservator. • Case transfers between regional offices. • Program transfers such as a disabled or blind recipient turns age 65, becoming an aged client. NOTE: In the system, name, address, SSN, race and gender can be changed or corrected on a processed time span.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page | 97 Effective Month: September 2023 101.16.05 TAKING ACTION ON REPORTED CHANGES Specialists must follow up on information which is reported by the recipient or otherwise becomes known to the agency to determine if the information is a reportable change. If the change is not reportable, the information will be considered at the next regular review. For instance, an income increase reported by the parent of a Medicaid or CHIP child is not a reportable change because of the continuous eligibility provision for children. The impact of an increase in parental income will be considered at the next review. However, if the parent reports an eligible child has moved from the state, that is a reportable change which must be acted upon. Action on a reportable change must be initiated no later than 10 working days from the date the change becomes known to the agency to determine its impact on eligibility and benefit level. NOTE: It is imperative that timely action be taken on reported changes to prevent agency error. For instance, recipients frequently report address changes. Failure to take prompt action on these changes not only results in inconvenience to the recipient, but also may lead to benefits being terminated in error when notices are mailed to the wrong address. If verification of a reportable change is needed from the recipient, DOM-307 will be issued with a 30 day deadline to provide written notice of the required information and due date. Action is taken on changes as follows: • Reported changes with the likelihood that eligibility will be adversely affected require development, which may mean a request for additional information is needed. Failure by the MAGI head of household or ABD recipient or representative to respond to needed information will result in termination of eligibility for any adult(s) affected by the change. Changes can include, but are not limited to, the report of a marriage with additional household income to consider, a new job for a household member or any type of change indicating an additional source of income.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page | 98 Effective Month: September 2023 • A negative change reported during a review period that affects eligibility for adult(s) is handled at the time of the reported change; however, it is not permissible to take punitive action on the children in a case due to action being taken for the adult’s eligibility. This includes not setting future termination dates for the children at the end of their 12-months of continuous eligibility. Children must be reviewed so their eligibility is assessed at each annual review. For example, an adult reports marriage and is terminated during the review period because spousal wages were requested but not verified. The non pregnant adult’s eligibility is terminated. A future closure would not be set for the children. The child’s eligibility must be reviewed at the next annual review. If information needed at the time of the annual review is not provided, the children’s eligibility would be terminated as a result of the annual review. • If there is a case change, such as the addition of a parent, that results in information that must be requested to confirm the parent’s eligibility, do not require updated information for a child’s eligibility. Handle the child’s eligibility at the next annual review. • Reported changes that will not likely affect eligibility for the household should be developed but if a request for additional information yields no response, it is not permissible to terminate eligibility for a failure to respond to the request. Instead, follow up at the next review. These types of changes may include a change of address for the household when a move out of state is not indicated, loss of an income source to the household, the death of a child’s parent or other types of changes that would not result in a loss of eligibility. • Reported changes or actions taken during a review period can affect one or more household members but not the entire household. The option to perform an early review can be offered but cannot be required for a child’s eligibility. • A change during the review period that results in updated information on all household members can result in eligibility being extended for the household. For example, during the review period a parent applies and is added to the case. All household income is updated and verified. It is permissible to extend eligibility for a new 12-month review period for the children under these circumstances.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page | 99 Effective Month: September 2023 • Reported changes that would change a child from CHIP to Medicaid must be acted on. Children cannot be switched from Medicaid to CHIP during the child’s 12 months of continuous eligibility Documenting the Case Record The case record/case narrative must reflect the following information about the reported change:

• Who reported the change. • When the change was reported. • How the change was reported. • When action was initiated on the change. • What was used to verify the change. • What action was taken regarding the verified information.

101.17 REINSTATEMENTS Certain situations require a reinstatement of services, which means either eligibility is restored, or Medicaid income is corrected for a prior period. Both types of reinstatements are completed without requiring that a new application be filed on behalf of the recipient. A reinstatement is in order in the following situations, as applicable, to ABD and MAGI recipients via a Reinstatement contact in the system. 101.17.01 INFORMATION PROVIDED PRIOR TO EFFECTIVE DATE OF CLOSURE If the recipient provides information that changes the adverse action decision or fully complies with unmet requirements prior to the effective date of the closure, benefits must be reinstated to ensure no loss of benefits, if the recipient remains eligible. If the information provided does not change the adverse action decision, no further action is required. If advance notice of Medicaid and/or CHIP benefit reduction or termination was not issued as required, benefits must be reinstated back to the date of closure

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page | 100 Effective Month: September 2023 at the time the error is discovered, regardless of whether the client is currently eligible. After benefits are reinstated, advance notice would then be issued to close the case to meet the advance notice requirements. Close the case at the end of the advance notice period. 101.17.02 90-DAY REINSTATEMENT PERIOD FOR MAGI AND ABD RENEWALS A 90-day reinstatement period is required for MAGI (including CHIP) and ABD renewal/review closures to allow eligibility to be reinstated retroactively to the effective date of the closure if the recipient is otherwise eligible. The 90-day reinstatement period, defined as 90-days from the effective date of the closure, allows Medicaid or CHIP eligibility to be reinstated without requiring a new application or updated signature. The 90-day reinstatement period applies to renewal/review closures due to: • Failure to return the MAGI or ABD renewal form, or • Failure to comply with renewal requirements by not providing requested information issued in writing on a DOM-307, Request for Information (and DOM-309, Second Request for Information, for ABD purposes). The 90-day reinstatement period is not associated with other types of reinstatements described in this section that either have no time limits for initiating a reinstatement or may have different time limits. These types of reinstatements are the result of corrective action needed, hearing decisions, known temporary closures for ABD and locating a recipient whose whereabouts were previously unknown. 101.17.02A RENEWAL CLOSURES REQUIRING REINSTATEMENT Reinstate a MAGI or ABD case that closed at renewal when either of the following conditions exists: • The case closed due to failure to return the renewal form, and a signed form (complete or incomplete) is returned within the 90-day period following the effective date of closure; or,

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page | 101 Effective Month: September 2023 • The case closed due to failure to provide needed information, and the requested information is provided in full or in part within the 90-day period following the effective date of closure. Effective Month of the Reinstatement The effective month of the reinstatement is the month following the month of closure. The exception to this rule is if there is a future closure date on file. For future closures, reinstate no earlier than the next calendar month after the current month. For example, if the reinstatement action is taken in July for a child with a closure date at the end of September, reinstate the case with a time period starting no earlier that October 1st. Requesting Additional Information to Process the Reinstatement If the renewal form is incomplete or the information provided is incomplete, attempt to handle these issues by telephone contact, if possible. If not possible, issue a DOM-307, Request for Information (and DOM-309A for ABD, if needed), specifying what is needed to comply with the renewal process and allow 15 days for the information to be returned. • If requested information is not provided, no further contact with the individual is required unless the information needed is provided during any remainder of the 90-day period. Close the reinstatement contact, delete the time period and document the case narrative. • If all information is provided, take action to process the case: o If eligible, approve using the reinstatement contact providing all eligible coverage. o If ineligible due to an eligibility-related reason, i.e., over income, handle as follows:  Cancel the reinstatement contact,  Set an application contact,  Use the 1st day of the month following the closure month as the application date. For example, if the case originally closed at the end of June (06/30), use the 1st of July (07/01) as the application date and the time period begin date.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page | 102 Effective Month: September 2023

101.17.02B RENEWAL REINSTATEMENT NOT REQUIRED A reinstatement is not required for a renewal closure if the renewal form is returned unsigned. • Upload the unsigned form in case documents and document the case accordingly, • Return the unsigned form via a manual 307, Request for Information for both MAGI and ABD renewals, advising the individual the attached form must be signed (Note: a 309 is not issued in this instance if the form is not returned). • If the signed form is subsequently returned within the 90-day period, handle as instructed in “Renewal Closures Requiring Reinstatement” described above.

101.17.03 CORRECTIVE ACTION At the time the agency becomes aware of an error which affects eligibility or level of benefits, action must be initiated to correct the error. Immediate corrective action is required to prevent further error. In some instances, it may also be necessary to correct an error retroactively into prior months. • When corrective action into prior months adversely affects the recipient, meaning the error caused the client to be totally ineligible or eligible for fewer benefits, DOM-354, Improper Payment Report, is prepared. • When corrective action into prior months favorably affects the client, meaning the client was eligible or eligible for more benefits, the corrective action is handled through reinstatement. When the agency has denied or terminated eligibility in error or reduced benefits in error for reasons such as failure to act on information present in the record or provided during the advance notice period, misapplication of policy, miscalculation of income or resources, untimely processing, etc., benefits must be reinstated retroactive to the month the error occurred.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page | 103 Effective Month: September 2023 The discovery source for the error may be: o Case reviews. o Applicant or recipient complaints. o Recognition by the specialist. o Other sources having knowledge of the error.

101.17.04 CONTINUATION OF BENEFITS AND HEARING DECISIONS When the client makes a timely hearing request during the advance notice period, benefits will be continued at the same level through the reinstatement process until a hearing decision is reached. When a decision, granting eligibility or increased benefits is rendered as a result of a state or local hearing, the regional office may be required to reinstate eligibility or when appropriate correct Medicaid Income, retroactive to the date decided by the hearing official. If benefits were continued in an active case pending the hearing decision, reinstatement may not be required unless the decision at the hearing is to increase the level of benefits in effect prior to the hearing. 101.17.05 TEMPORARY CASE CLOSURE When it is known that a client will be ineligible for two months or less, the closure is processed in the usual manner; however, at the end of the temporary period, the case may be reinstated without completing new eligibility forms necessary for reapplication. The case record will show: o The exact length of time during which ineligibility will exist. o The date the recipient will be eligible again. o The reason for the temporary ineligibility.

In this situation a break in eligibility correctly exists; therefore, it is necessary to adjust the eligibility begin date to reflect the most recent eligibility begin date.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page | 104 Effective Month: September 2023 101.17.06 WHEREABOUTS UNKNOWN As indicated previously, eligibility must be terminated if a client’s whereabouts remain unknown after the agency has (1) received returned mail with no forwarding address and (2) made reasonable efforts to locate the recipient. Reasonable effort means: • At least two attempts to contact beneficiary • Attempt to contact through at least 2 modalities (such as, mail, phone, email) • If there are not two ways to contact the client on file, document in the case narrative why 2 modalities couldn’t be attempted. • Allow at least 30 days for the beneficiary to respond. If the client’s location subsequently becomes known during the time he is eligible, benefits will be reinstated. For a child who has continuous eligibility, Medicaid and/or CHIP benefits must be reinstated with no loss. For an adult, the specialist must determine eligibility for each month that the adult recipient’s whereabouts were unknown and reinstate for any period he would have been eligible.

101.18 OTHER CHANGES – ABD PROGRAMS

101.18.01 CHANGES IN MEDICAID INCOME The amount of income an institutional client must pay to the nursing facility toward the cost of his care is known as Medicaid Income. Changes in income, marital status or non-covered medical expenses will either increase or decrease Medicaid income. The effective dates of such changes are determined as follows:

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page | 105 Effective Month: September 2023 Decrease in Medicaid Income A change which results in a decrease in Income is effective the month in which the change is reported or becomes known to the agency. For example, a decrease in income reported any time in the month of June will be effective as of June 1. The notice issued to the client and to the facility will specify June 1.

Increase in Medicaid Income A change which results in an increase in Medicaid Income requires advance notice to the client advising of the increase. However, advance notice for Medicaid Income increases is based on issuing notice 10 days before the date Medicaid makes its payment to the facility. A nursing home cannot submit a claim for any month’s payment until the first day of the following month. Payment is then made to the facility on the first Monday following receipt of the claim. This means the specialist has 10 days before Medicaid makes its payment to a facility to increase Medicaid Income for the current month. Since payment schedules may vary, policy governing increasing Medicaid Income in the current month is based on whether advance notice can be issued 10 calendar days before the first of the following month. Example: An increase in a recipient’s income is discovered on October 10, Medicaid Income can be increased effective October 1 if advance notice of the increase is issued no later than October 21. NOTE: If a state or local hearing is requested within the advance notice period, the increase cannot be effective until the final hearing decision is rendered. Temporary Decrease in Medicaid Income When Medicaid Income is temporarily decreased due to the allowance of a deduction, i.e., health insurance premium or other non-covered medical expense, and Medicaid Income is subsequently returned to the amount previously in effect, this action is not considered an increase in Medicaid Income subject to advance notice.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page | 106 Effective Month: September 2023 When the client is notified of the allowance of the deduction, the notice should also advise that Medicaid Income will return to the previous amount and specify the amount and date Medicaid income will resume. In any instance where Medicaid Income does not revert back to the amount in effect prior to allowance of a deduction, an increase would require advance notice.

Increase in Medicaid Income Combined with a Closure In instances where income is counted in the month received, but receipt of the income also renders the client ineligible, the excess income is included in the Medicaid Income computation provided there are 10 calendar days left in the month of receipt to allow for advance notice. In addition to increasing Medicaid Income for the month of receipt, the case is also scheduled for closure. Example: A client receives a lump sum VA payment of $4000 in December which is reported to the regional office on December 12. Action is taken to include the $4000 as income for December for Medicaid Income purposes. On December 19, notice is issued to allow advance notice of the increase in Medicaid Income effective December 1 and closure for January 31st due to excess resources for January. The amount of Medicaid Income due for the month will be the actual shown on the notice or the Medicaid reimbursement rate for the facility, whichever is less. The client or representative must be advised to contact the facility to obtain the lesser of the two amounts. Temporary Increase in Medicaid Income When excess resources are not an issue, but receipt of additional income results in the monthly income total being over the income limit for LTC, the case will remain open if, for whatever reason, there is not time to allow advance notice of closure. However, if there are 10 calendar days left in the month, Medicaid Income must still be increased to the amount of that month’s income or the Medicaid reimbursement rate for the facility, whichever is less.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page | 107 Effective Month: September 2023 The client or representative must be advised to contact the facility to obtain the lesser of the two amounts. For the following month, eligibility will continue. The additional income will be removed from the Medicaid Income calculation and Medicaid Income will return to the amount in effect prior to the temporary income increase. Example: A client receives a lump sum VA payment of $2500 in December which is reported to the regional office on December 21. The office became aware of the income too late to close the case; however, action is taken on December 21 to include the $2500 as income for December for Medicaid Income purposes. On December 21, notice is issued to allow advance notice of the increase in Medicaid Income effective December 1. The lump sum did not cause resources to exceed the limit; therefore, eligibility continues. The income is removed from the Medicaid Income calculation and Medicaid income returns to the prior amount effective January. 101.18.02 CHANGE TO A REDUCED SERVICE COVERAGE GROUP Changing from a full-service coverage group to a reduced coverage group requires advance notice before the change can be effective the following month. It is not possible to change an active full-service case to a reduced service coverage group such as QMB, SLMB, or QI in the system for the following month after the established deadline dates for advance notice.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page | 108 Effective Month: September 2023

101.18.03 WOMEN IN HEALTHIER MS WAIVER OR MEDICARE COST- SHARING GROUPS TRANSITIONING TO COE-088 FOR PREGNANCY AND POST-PARTUM ELIGIBILITY The Healthier MS Waiver (HMW) and Medicare Cost Sharing eligibility groups do not cover pregnancy-related services. If a woman is active in the HMW or as a QMB, SLMB or QI and reports that she is pregnant and needs pregnancy-related coverage, take the following action: • Obtain her expected due date, • Using information from her ABD application or last review form, use non- filer MAGI household composition and budgeting rules to determine her eligibility for COE-088, • If eligible, transition her to COE-088 for the duration of the pregnancy and post-partum period. MEDS will set a review date for the end of her post partum period. Evaluate eligibility for all COEs (ABD and MAGI) when completing her review after the 12 month post partum period. • If ineligible for COE-088 using non-filer rules, contact the ABD recipient to confirm whether the use of non-filer rules is appropriate. If the recipient is a tax filer or dependent of a tax filer, apply filer rules as appropriate to determine eligibility for COE-088. o If eligible using filer rules, transition ABD recipient to COE-088 for the duration of the pregnancy and post-partum period. At the end of her post-partum period, the system will automatically transfer her back to her original ABD COE. If her annual review is due or overdue, give priority to completing the needed redetermination of ABD eligibility. o If ineligible using filer rules or if filer rules do not apply and the ABD recipient is ineligible using non-filer rules, issue a manual DOM-305, Notice of Action, advising the ABD recipient that she is not eligible for Medicaid as a pregnant woman but that she remains eligible in her original ABD coverage group.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page | 109 Effective Month: September 2023 101.19 OTHER CHANGES – MAGI PROGRAMS 101.19.01 TRANSITIONING THE PREGNANT CHIP CHILD TO MEDICAID COE-088 For most children, program changes are effective only at review because of the continuous eligibility provision for children. However, when the agency becomes aware that a CHIP child is possibly pregnant, a special review must be completed to verify pregnancy/due date. There is no need to determine if the minor is eligible for Medicaid coverage as a pregnant woman, because pregnant minors have income exemptions that assure eligibility. If pregnant, enter the due date in the system, process eligibility and the child will transition from CHIP to COE-088 Medicaid for the duration of the pregnancy and post-partum period. However, if the office learns of the change too late, i.e., the minor is at the end of her pregnancy or has already delivered, no action is taken to change the program. The program transition from CHIP to Medicaid is an adverse action. If action is taken by the 15th of the current month, CHIP will terminate at the end of the current month and the pregnant minor will move to Medicaid COE-088 the following month. If action is taken after the 15th, CHIP will continue for another month before transitioning to Medicaid. The head of household is issued a notice which contains the following information about the child’s eligibility: • Date the pregnant child will be removed from CHIP; • Date the child will be eligible for Medicaid as a pregnant woman. • The verified delivery date and the requirement to report an earlier or later date. • Date the child will become ineligible for Medicaid as a pregnant woman. • The child’s review due date. • Information about coverage for a 12-month post-partum period. • The deemed eligible provision for children born to Medicaid-eligible women. When the pregnant minor’s review comes due at the end of her postpartum period while she is on COE-088, the review will be completed. If the child is eligible for full Medicaid or CHIP, action can be taken to change the child from

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page | 110 Effective Month: September 2023 COE-088 to the appropriate MAGI or CHIP coverage group for a child under age 19 effective with the month following postpartum coverage. 101.19.02 WOMEN IN THE FAMILY PLANNING WAIVER (FPW) TRANSITIONING TO COE-088 FOR PREGNANCY AND POST-PARTUM ELIGIBILITY The Family Planning Waiver does not cover pregnancy related services. If a woman is active in the FPW and reports that she is pregnant, obtain her expected due date and enter it into the system so that she will transition to COE-088 for the duration of her pregnancy and post-partum period. Since the FPW uses non-filer rules to determine eligibility and non-filer rules would apply to the transition determination, there is no requirement to do a new or updated determination.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 111

Effective Month: March 2018 101.20 APPLICATION AND REVIEW SUMMARY CHART ACTION POLICY REQUIREMENT PROCEDURAL REQUIREMENTS Filing an Application, Submitting a Renewal Form, and Reporting Changes Means of submission: • In-person at any location where eligibility staff are on official duty • By mail to the agency, RO or Central Office (CO) • By fax to the agency (RO or CO) • Applications may be submitted on- line at www.medicaid.ms.gov. • By telephone – The telephonic signature must be recorded. • Applications and renewal forms may be submitted online through the Common Web Portal Applications & Renewal Forms must be signed but an original signature not required. Telephone signatures are recorded versions. Who Can File an Application • Adult applicants • Certain minors (pregnant, married, living independently, applying for own children) • Parent with primary physical custody or either parent if true joint custody exists • Caretaker relative • Authorized, designated or legal representative If application filed by incorrect person, do not deny; get signature of correct person.

Applications must be signed to be valid. Authorizing a Representative (types allowed) 1) Authorized Representative – applicant or recipient designates in writing. Can be a person or organization. Limits can be placed on rep’s rights to act. 2) Self-Designated Rep – must be an individual except for owner/operator of state owned MAGI application form used to designate authorized rep for MAGI cases. DOM- 302A required for ABD authorized rep.

Self-Designated requires DOM-302B;

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 112

Effective Month: March 2018 ACTION POLICY REQUIREMENT PROCEDURAL REQUIREMENTS LTC facility. Rights are not limited. Applicant must be incapable of designating authorized rep. 3) Legal Rep – legally appointed by court or other legal document (such as POA) and must be legally authorized to make healthcare decisions for applicant/recipient. Can be an executor of deceased applicant’s estate. Legal rep requires DOM-302C.

Filing Date of an Application The date a signed application is filed or received by the agency (RO or CO) by any means of submission for filing an application. The date received by DOM or the FFM is the date filed Medicaid Applications Filed Outside of DOM 1) SSI applications, 2) Children in the custody of DCPS who are certified as eligible by DCPS, 3) Medicaid or CHIP applications filed with the FFM and transferred to DOM, 4) LIS applications filed with SSA and transferred to DOM, 5) HPE applications filed with qualified hospitals and PEP applications filed with providers/entities and transferred to DOM. DOM determines eligibility for FFM, LIS, HPE, and PEP applications.

RO with Responsibility RO that serves the county where at-home recipients live is responsible for the case. Long term care cases are handled by RO that serves the county where the facility is located. Combo MAGI/ABD cases with one in a facility is handled by RO

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 113

Effective Month: March 2018 ACTION POLICY REQUIREMENT PROCEDURAL REQUIREMENTS where facility is located. Timely Processing of Applications (SOP or Standard of Promptness) • 45 days for MAGI and ABD if no DDS decision needed. • Applications filed with FFM have a SOP beginning with date received by DOM; filing date is date filed with FFM. • 90 days for ABD if DDS decision needed. Days are counted from date of filing application to decision date, except those filed with FFM.

Making an Eligibility Decision Verification of eligibility factors comes from data available from electronic data sources and/or the applicant. If data is unavailable from data sources or if applicant provided information is inconsistent, verify independently, which includes obtaining from applicant.

Case documentation is required to support an eligibility decision. Use the Case Narrative or document within the case record. Issuing Requests for Information (RFI) ABD applications utilize a 307 (1st RFI) and 309 (2nd RFI). If additional time is requested, hold to end of allowed processing time period applicable. MAGI applications require direct contact 1st, then utilize a 307 (1st RFI). If additional time is requested, hold to end of 45 days. Refer to “Reasonable Efforts to Assist All Applicants” to avoid multiple denials of eligibility when the applicant is incapable, or rep is unwilling to provide needed information. Compliance After Denial If MAGI or ABD applicant fully complies by providing needed information by the end of the month following the month of denial, use denied application and application date and reinstate the application.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 114

Effective Month: March 2018 ACTION POLICY REQUIREMENT PROCEDURAL REQUIREMENTS MAGI Application Indicates Possible ABD Eligibility If a MAGI applicant indicates possible disability, issue the ABD DOM-300 & request only information not available through MAGI process. A signed ABD application is required. If ABD application is not received, process the MAGI application. FFM applicants indicating disability are sent a non-MAGI letter that must be signed & returned to start ABD process. Determining Beginning Dates of Medicaid Eligibility If all factors of eligibility are met, the begin date is: • 1st of month of application, or • 1st day of the 1st, 2nd or 3rd month prior to the month of application. • QMB eligibility begins no earlier than the month following the month of approval. • HPE and PEP eligibility begins on the day of the month the hospital determines an individual to be eligible for HPE and providers/entities determine an individual to be eligible for PEP. Retroactive Medicaid does not have to be authorized at the time of application. It can be requested and added at any point in time. Determining Beginning Date of CHIP Eligibility • 1st of month following month of application eff. 12/01/2016 • If a newborn application is taken within 31 days of birth and approval is authorized within 60 days of application, CHIP eligibility is retroactive to the date of birth. There is no retroactive eligibility for CHIP eligible children, except newborns. Determining End Dates of Eligibility For Medicaid and CHIP, the end date of eligibility is either: • The last day of the month that eligibility ends, • The death date of the recipient,

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 115

Effective Month: March 2018 ACTION POLICY REQUIREMENT PROCEDURAL REQUIREMENTS • The date of entry into a public institution. • HPE and PEP ends the last day of the month of the HPE and PEP period or the actual day of the month that the full application for Medicaid is denied. Filling in the Gap for SSI Eligibles Missing months of SSI eligibility may be evaluated with the application for retroactive Medicaid or under a separate application at a future date. SSI payments begin the month following the month of application. The month of application is the E02 month. DOM covers the E02 month automatically since SSI determines the person eligible for the E02 month. Processing Applications & Renewals of DOM Employees & Family Members Medicaid or CHIP cases involving DOM employee family members may not be handled directly or indirectly by the DOM employee with the family relationship. Assigned Central office staff is responsible for processing applications and renewals. Ensuring Continuous Eligibility for Children under Age 19 Children determined eligible at the time of application and renewal are locked into a protected period of eligibility for 12-full months. Only a limited number of early termination reasons can interrupt the 12- months of continuous eligibility. Applies to both MAGI-related children and ABD children Ensuring Eligibility for the 1st Year of Life for the Deemed Eligible Infant An infant born to a Medicaid-eligible mother is eligible from the date of birth through the month the child reaches age one (13 months). Central Office staff inputs deemed eligible infant eligibility upon direct notification by

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 116

Effective Month: March 2018 ACTION POLICY REQUIREMENT PROCEDURAL REQUIREMENTS the birthing hospital.

Assigning Review Due Month at Application MAGI – Medicaid application month starts the 12-month count. MAGI – CHIP benefit month starts the 12-month count. MAGI application month (Medicaid) or benefit month (CHIP) + 11 months = review due date. MAGI -Pregnant Post-Partum review will be set for 12 months after the pregnancy ends.

ABD – month of supervisor authorization starts the 12-month count ABD authorization month + 11 months = review due date. Assigning Review Due Month at Redetermination MAGI and ABD are determined using the time period begin month to start the 12-month count. Begin month of time period + 11 months = review due date. Administrative Renewal Processing If eligibility can be approved in the same program (Medicaid or CHIP or ABD in the same COE) based on updated data from electronic data sources and reliable case record information, then the recipient is notified of the approval and asked to report any changes. Any changes reported are acted on as part of the redetermination process. ABD cases with an asset test can be renewed through this process. Adm. renewals must be initiated before scheduled mailings of pre- populated forms. Processing Renewals Using Pre-Populated Review Forms Pre-populated renewal forms are issued by MEDS for MAGI & ABD cases. Due date for return of the signed form MAGI and ABD form is 30- days from date form is issued. Returned forms with missing information require the use of a309 for ABD and telephone contact for MAGI. New or Refer to the Reinstatement policy for compliance after termination.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 117

Effective Month: March 2018 ACTION POLICY REQUIREMENT PROCEDURAL REQUIREMENTS additional information requires use of 307 (MAGI) and 307/309 (ABD). Must attempt telephone contact prior to terminating (for MAGI and ABD) to try to secure missing information. Timely Authorization of a Renewal Review is timely if authorized by the last day of the month in which review is due. If case is closed, action to close must be authorized by the adverse action deadline date. Reviews are considered overdue if not authorized timely. Adverse Action Deadline(s) for Advance Notice Advance notice (10-days) is required to take an adverse action. The deadline is the 15th day of the current month (exception is February – deadline is the 13th) to allow 10- days advance notice plus 5-days mailing time.

Adverse action must be authorized on or before the deadline date to be effective the following month. Advance Notice to Reduce or Terminate Benefits Advance notice is required to: • Terminate eligibility • Convert a case to a reduced services COE (QMB, SLMB, QI) • Terminate a nursing facility per diem payment • Switch from CHIP to Medicaid or Medicaid to CHIP Advance Notice = 15 full days following the date an adverse action is taken on a case. Medicaid Income increase is the exception. Advance Notice to Increase Medicaid Income Advance notice is 10-days before the date DOM makes its payment to the nursing facility, which is always in the month following the current month. Advance notice is 10 calendar days before the 1st of the following month for the change to be effective

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 118

Effective Month: March 2018 ACTION POLICY REQUIREMENT PROCEDURAL REQUIREMENTS in current month. Requirement for Ex Parte Reviews Any recipient losing eligibility in one COE must be reviewed under any/all available COE’s using existing information prior to terminating eligibility. If additional information is needed, allow a reasonable opportunity to provide additional information which may include a separate application form (ABD to MAGI & vice versa).

If recipient is being terminated for failure to comply with the renewal process, an ex parte review is not applicable. SSI Terminations Due to Excess Income or Resources These types of SSI terminations are issued an SSI Redetermination Form for possible eligibility in a Medicaid COE. An abbreviated review form is issued by the system. Continuing eligibility is decided using the completed review form along with data on the SDX and SVES records. If additional information is needed, contact with the individual may be required. An SSI renewal is a type of ex parte review; however, all factors of eligibility must be verified. Renewal Processing MAGI and ABD renewals may be returned to the RO by any means allowed for submission of an application. Telephone renewals that are not recorded must be sent to the recipient for signature. Renewals and 12- Months of Continuous Eligibility for Children Children in a case may have different review due dates. Attempt alignment of review dates at the time of renewal if possible but continuous eligibility cannot be shortened (without a written request from the parent/caretaker). A new period of continuous eligibility can be assigned when Children require a full review at the end of their 12-month protected period of eligibility; future end dates

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 119

Effective Month: March 2018 ACTION POLICY REQUIREMENT PROCEDURAL REQUIREMENTS eligibility is reestablished for all HH members. are not permitted.

Special Reviews due to Reported Changes Reported changes that result in a negative action for adult(s) in the case cannot affect eligibility for children in the case. Reported changes that will not affect eligibility for the household must be acted on, but do not terminate eligibility if a request for information yields no response. Children must be reviewed at the end of their 12-month review period; no future closure dates are permitted. Changes from CHIP to Medicaid must be acted on. Reported changes resulting in updated information on all household members can result in a new annual review period for the HH.

Reinstatements Due to Failure to Issue Advance Notice If advance notice was not issued as required to reduce benefits or terminate eligibility, reinstate eligibility for all affected months then issue advance notice to terminate or reduce benefits. Reinstate regardless of whether HH or individual is eligible to remedy failure to issue advance notice. 90-Day Reinstatement Period for MAGI & ABD Compliance within 90-days following effective date of closure to return the signed renewal form and/or provide requested information will result in reinstatement back to the date of closure. If additional information is needed, attempt telephone contact 1st, then use 307 (MAGI/ABD) and 309 (ABD). • If information not provided, no further action required except to close the reinstatement contact & delete time period. This rule is not applicable for the return of unsigned renewal forms.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 120

Effective Month: March 2018 ACTION POLICY REQUIREMENT PROCEDURAL REQUIREMENTS • If information provided & eligibility is established, approve reinstatement. • If information provided & ineligibility exists, cancel the reinstatement & set an application contact. Refer to policy for details. Corrective Action Requirements If corrective action adversely affects a recipient, handle via completion of an Improper Payment Report. If corrective action favorably affects a recipient, handle as a reinstatement back to the month the error occurred. There is no time limit imposed for corrective action.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Table of Contents Effective Month: March 2018 Table of Contents 101.01 INTRODUCTION ......................................................................................................... 100 101.02 COVERAGE OF THE CATEGORICALLY NEEDY IN MISSISSIPPI ........... 101 101.02.01 MANDATORY CATEGORICALLY NEEDY – MAGI RELATED ................. 102 101.02.02 MANDATORY CATEGORICALLY NEEDY - ABD ....................................... 105 101.02.03 MANDATORY CATEGORICALLY NEEDY – SPECIAL GROUPS ............ 107 101.02.04 OPTIONAL CATEGORICALLY NEEDY – MAGI-RELATED ...................... 108 101.02.05 OPTIONAL CATEGORICALLY NEEDY – ABD ............................................ 110 101.03 HOW TO APPLY ....................................................................................................... 200 101.03.01 APPLICANT .......................................................................................................... 200 101.03.01A Deceased Applicants ................................................................................... 200 101.03.01B Non-Applicants ............................................................................................. 200 101.03.02 DOM APPLICATION FORM(S) ....................................................................... 200 101.03.03 SIGNATURE REQUIREMENTS ...................................................................... 201 101.03.04 REPRESENTATIVES AUTHORIZED TO ACT FOR AN APPLICANT ..... 203 101.03.05 WHO CAN FILE THE APPLICATION ........................................................ 205 101.03.06 ACCESS AND ACCOMMODATION IN APPLYING ............................... 206 101.03.07 REASONABLE EFFORTS TO ASSIST .................................................... 208 101.04 FILING THE APPLICATION ...................................................................................... 225 101.04.01 RIGHT TO APPLY ........................................................................................ 225 101.04.02 REQUEST FOR AN INFORMAL MEDICAID ELIGIBILITY OPINION ..... 225 101.04.03 SUBMITTING AN APPLICATION AND APPLICATION FILE DATE ......... 226 101.04.04 PROTECTED APPLICATION DATES FOR MEDICAID APPLICANTS228 101.04.05 APPLICATIONS RECEIVED FROM MS RESIDENTS OUT-OF-STATE ..

......................................................................................................................... 228 101.04.06 OUT OF STATE APPLICANTS .................................................................. 229 101.04.07 RESIDENCE CHANGE DURING THE APPLICATION PROCESS ...... 229 101.04.08 WHERE TO FILE THE APPLICATION ..................................................... 229

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Table of Contents Effective Month: March 2018 101.04.09 VOTER REGISTRATION ................................................................................. 233 101.05 MEDICAID APPLICATIONS FILED THROUGH ANOTHER AGENCY OR ENTITY ....................................................................................................................................... 250 101.05.01 APPLICATIONS FOR SSI APPLICANTS ...................................................... 251 101.05.02 APPLICATIONS FOR FOSTER CHILDREN AND ADOPTION ASSISTANCE CHILDREN CERTIFIED BY THE DEPARTMENT OF CHILD PROTECTION SERVICES (DCPS) ................................................................................... 252 101.05.03 ACCOUNT TRANSFERS (AT’S) RECEIVED FROM THE FFM ................ 252 101.05.04 LOW INCOME SUBSIDY (LIS) APPLICATIONS RECEIVED FROM SSA ................................................................................................................................................. 253 101.05.05 HOSPITAL PRESUMPTIVE ELIGIBILTY (HPE) .......................................... 255 101.06 IN-PERSON INTERVIEWS WITH DOM .................................................................. 275 101.06.01 INTERVIEW DISCUSSION ......................................................................... 275 101.06.02 CONCLUDING THE INTERVIEW .............................................................. 278 101.07 STANDARDS OF PROMPTNESS ........................................................................... 300 101.07.01 REGIONAL OFFICE RESPONSIBILITIES ............................................... 300 101.07.02 EXCEPTIONS TO TIMELY PROCESSING ............................................. 300 101.07.03 ABD STANDARDS OF PROMPTNESS ................................................... 301 101.07.04 MAGI-RELATED STANDARD OF PROMPTNESS ................................ 301 101.08 PROCESSING APPLICATIONS ............................................................................... 325 101.08.01 MAKING AN ELIGIBILITY DECISION ....................................................... 325 101.08.02 USE OF COLLATERAL CONTACTS ........................................................ 327 101.08.03 REQUESTING INFORMATION FROM THE APPLICANT .................... 328 101.08.03A ELECTRONIC DATA SOURCES UTILIZED BY DOM ....................... 329 ELECTRONIC DATA SOURCES UTILIZED BY DOM (Continued) .......................... 330 101.08.03B ELECTRONIC DATA SOURCES UTILIZED BY THE FFM ............... 330 101.08.04 SUPERVISORY REVIEW ........................................................................... 331 101.08.05 APPLICATION ACTIONS ............................................................................ 331 101.08.06 COMPLIANCE AFTER DENIAL ................................................................. 332 101.09 COMBINATION MAGI AND ABD APPLICATIONS ............................................. 350

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Table of Contents Effective Month: March 2018 101.10 ELIGIBILITY DATES ................................................................................................ 375 101.10.01 BEGINNING DATES OF MEDICAID ELIGIBILITY.................................. 375 01.10.02 BEGINNING DATES OF CHIP ELIGIBILITY ............................................... 375 101.10.03 TERMINATION DATES ............................................................................... 376 101.10.04 RETROACTIVE MEDICAID ELIGIBILITY ................................................. 376 101.10.04A RETROACTIVE MEDICAID FOR ABD APPLICATIONS ...................... 377 101.10.04B RETROACTIVE MEDICAID FOR MAGI-RELATED APPLICATIONS ...

..................................................................................................................... 378 101.10.05 RETROACTIVE MEDICAID FOR DECEASED APPLICANTS .............. 378 101.10.06 RETROACTIVE MEDICAID FOR SSI ELIGIBLES AND FILLING IN GAPS ......................................................................................................................... 378 101.11 NOTIFICATION ......................................................................................................... 400 101.11.01 ADVANCE NOTICE ........................................................................................... 400 101.11.02 EXCEPTIONS TO ADVANCE NOTICE ......................................................... 401 101.12 PROCESSING DOM EMPLOYEES/FAMILY MEMBERS CASES ................... 450 101.13 SERVICE DELIVERY SYSTEMS .......................................................................... 450 101.14 CONTINUOUS ELIGIBILITY FOR CHILDREN .................................................... 475 101.14.01 EARLY TERMINATION REASONS FOR CHILDREN ........................... 475 101.14.02 DEEMED ELIGIBLE INFANTS .................................................................. 477 101.14.03 ADULTS ........................................................................................................... 478 101.15 THE REDETERMINATION OR RENEWAL PROCESS ..................................... 500 101.15.01 REGULAR REDETERMINATIONS OR RENEWALS – MAGI & ABD . 500 101.15.01A FREQUENCY OF REVIEWS .................................................................. 500 101.15.01B PROCESSING CHILDREN CURRENTLY DUE FOR REVIEW ..... 501 101.15.01C PROCESSING CHILDREN NOT CURRENTLY DUE FOR REVIEW ....

..................................................................................................................... 501 101.15.01D PROCESSING AN APPLICATION AND A REVIEW ............................. 502 101.15.02 ASSIGNMENT OF REVIEW DUE DATES ............................................... 503 101.15.03 ADMINISTRATIVE RENEWALS ................................................................ 505

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Table of Contents Effective Month: March 2018 101.15.04 PRE-POPULATED RENEWALS ..................................................................... 507 101.15.05 RETURNED MAIL FROM REDETERMINATIONS ...................................... 509 101.15.06 TIMELY PROCESSING ............................................................................... 510 101.15.07 TIMELY AUTHORIZATION ........................................................................ 511 101.15.08 EXPARTE REVIEWS ................................................................................... 512 101.15.09 SSI REVIEWS REQUIRED FOR SSI TERMINATIONS ......................... 515 101.15.10 RECEIPT OF REGULAR REVIEW FORMS ............................................ 516 101.15.11 DISPOSITION OF A REGULAR REVIEW – ABD AND MAGI .............. 517 101.15.11A APPROVAL OF A REGULAR REVIEW ................................................... 517 101.15.11B REDUCTION OR TERMINATION OF BENEFITS .................................. 517 101.15.12 REQUESTED INFORMATION PROVIDED AFTER CLOSURE ........... 519 101.16 SPECIAL REVIEWS ................................................................................................. 600 101.16.01 RECIPIENT REPORTING REQUIREMENTS ............................................. 600 101.16.02 CHANGE REPORTING REQUIREMENTS - ABD .................................. 601 101.16.03 CHANGE REPORTING REQUIREMENTS – MAGI PROGRAMS ....... 602 101.16.04 PROCEDURAL CHANGES – ABD and MAGI .............................................. 603 101.16.05 TAKING ACTION ON REPORTED CHANGES ............................................ 604 101.17 REINSTATEMENTS ................................................................................................... 700 101.17.01 INFORMATION PROVIDED PRIOR TO EFFECTIVE DATE OF CLOSURE ................................................................................................................................................. 700 101.17.02 90-DAY REINSTATEMENT PERIOD FOR MAGI AND ABD RENEWALS ................................................................................................................................................. 701 101.17.02A RENEWAL CLOSURES REQUIRING REINSTATEMENT ................... 702 101.17.02B RENEWAL REINSTATEMENT NOT REQUIRED .................................. 703 101.17.03 CORRECTIVE ACTION .................................................................................... 704 101.17.04 CONTINUATION OF BENEFITS AND HEARING DECISIONS ................. 705 101.17.05 TEMPORARY CASE CLOSURE .................................................................... 705 101.17.06 WHEREABOUTS UNKNOWN ......................................................................... 706 101.18 OTHER CHANGES – ABD PROGRAMS ................................................................ 800

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Table of Contents Effective Month: March 2018 101.18.01 CHANGES IN MEDICAID INCOME ................................................................ 800 101.18.02 CHANGE TO A REDUCED SERVICE COVERAGE GROUP .................... 800 101.18.03 WOMEN IN HEALTHIER MS WAIVER OR MEDICARE COST- SHARING GROUPS TRANSITIONING TO COE-088 FOR PREGNANCY AND POST-PARTUM ELIGIBILITY ............................................................................................ 800 101.19 OTHER CHANGES – MAGI PROGRAMS .............................................................. 800 101.19.01 TRANSITIONING THE PREGNANT CHIP CHILD TO MEDICAID COE-088 ................................................................................................................................................. 800 101.19.02 WOMEN IN THE FAMILY PLANNING WAIVER (FPW) TRANSITIONING TO COE-088 FOR PREGNANCY AND POST-PARTUM ELIGIBILITY ....................... 800 101.20 APPLICATION AND REVIEW SUMMARY CHART ............................................... 950

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |100 Effective Month: December 2016 101.01 INTRODUCTION This chapter provides information on coverage of categorically needy individuals in Mississippi and guidelines for processing applications, annual reviews of eligibility, special reviews of eligibility due to reported changes and reinstatements of eligibility for all Medicaid coverage groups and the Children’s Health Insurance Program (CHIP). • Coverage of the categorically needy is either mandatory or optional. Mandatory groups are required by the passage of federal laws and optional groups are authorized by the passage of state laws. • The application process consists of all activities completed during the timely processing period from the time a signed application form is received by the agency until a notice of approval or denial is mailed to the applicant. • An annual review or renewal of eligibility is a full review of all variable eligibility factors, conducted at specific intervals, not to exceed 12 months for each recipient, to determine whether or not eligibility continues. Basic information that is not subject to change is not re-verified. • A special review deals with reported changes that occur during a review period. The impact of each reported change must be evaluated to determine when, how and if the change impacts eligibility. • A reinstatement reopens eligibility without requiring a new application or renewal form. Eligibility may or may not be reopened back to the date of closure, depending on the circumstances. Other changes are also addressed in this chapter that are program specific, such as increases in Medicaid Income and transitioning pregnant women from their original source of eligibility to pregnancy related coverage, when necessary.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |101 Effective Month: December 2016 101.02 COVERAGE OF THE CATEGORICALLY NEEDY IN

MISSISSIPPI Medicaid programs in each state must provide coverage to specified categories of needy individuals that include: • Children, • Pregnant women, • Parents or caretaker relatives of dependent children, • Aged individuals and • Disabled or blind individuals.

Within these broad categories of coverage, the specific groups covered are either: • Mandatory – meaning federal law required coverage of the category, or • Optional – meaning federal law allows coverage of the category and state law authorizes the coverage.

Coverage for children, pregnant women and parents and caretaker relatives are referred to as MAGI-related coverage due to the application of Modified Adjusted Gross Income (MAGI) standards to these groups. MAGI standards are financial methodologies used to determine eligibility. Income standards for MAGI-related coverage are referred to as MAGI-equivalent standards. Effective January 1, 2014, federal law referred to as the Affordable Care Act or ACA required that net income thresholds in effect prior to the ACA be converted to equivalent MAGI levels to account for income disregards eliminated by the ACA. Coverage of the aged, blind and disabled are referred to as ABD coverage. ABD policy is based on the most closely related cash assistance program, which is the Supplemental Security Income (SSI) program. The ABD program area uses SSI policy rules except in categories that have been allowed to use more liberal methodologies through State Plan approval or in instances where Medicaid regulations implement Medicaid policy that takes precedence over SSI policy. Refer to the Categories of Eligibility (COE) Chart in the Appendix page by the same name for COE designations, sources of eligibility and other identifying information that is pertinent to each group.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |102 Effective Month: December 2016 Certification Responsibilities Medicaid is certified or authorized by the following entities: 1. The Social Security Administration or SSA, 2. The Mississippi Department of Child Protection Services or DCPS, 3. The Mississippi Division of Medicaid or DOM, and 4. Qualified Hospitals that certify Hospital Presumptive Eligibility or HPE.

101.02.01 MANDATORY CATEGORICALLY NEEDY – MAGI RELATED The following are MAGI-related coverage groups that must be covered, as required by federal law: Mandatory Coverage of Parents and Other Caretaker Relatives Coverage is mandatory for parents and other caretaker relatives who have a dependent child or children under the age of eighteen (18) living in the home whose household income is below the applicable limit established by the state for coverage. The limit established by the state is a MAGI-equivalent standard based on household size. The Division of Medicaid certifies eligibility for this group. • Extended Medicaid coverage for twelve (12) months is mandatory for a family whose eligibility is based on family coverage if the family loses Medicaid coverage solely due to increased income from employment or increased hours of employment provided the family received Medicaid in any three (3) or more months during the six (6) month period prior to becoming ineligible, as determined by the Division of Medicaid. • Extended Medicaid for a maximum of four (4) months is required if a new collection or increased collection of child support (prior to January, 2014) or spousal support under title IV-D of the Social Security Act results in the termination of Medicaid for a family whose eligibility is based on family coverage described above, as determined by the Division of Medicaid.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |103 Effective Month: December 2016 Mandatory Coverage of Pregnant Women Coverage is mandatory for pregnant woman whose household income is at or below the income standard established by the state, not to exceed 185% of the federal poverty level converted to a MAGI-equivalent standard. The Division of Medicaid certifies eligibility for this group. • DOM must provide Medicaid for an extended period following termination of pregnancy to women who applied for and were eligible and received Medicaid services on the day that their pregnancy ends. This period extends from the last day of pregnancy through the end of the month in which a 60-day period ends. • Eligibility must be provided regardless of changes in the woman’s financial circumstances that may occur within this extended period. Mandatory Coverage of Newborns Coverage is mandatory for infants born to Medicaid eligible mothers. The infant is deemed eligible for one (1) year from the date of birth. This provision applies in instances where the labor and delivery services were furnished prior to the date of application and covered by Medicaid based on retroactive eligibility. The Division of Medicaid is responsible for certifying eligibility for deemed eligible newborns. Coverage is mandatory for infants born to qualified or non-qualified alien mothers who qualify for Medicaid on all factors other than alien status who receive Medicaid on the basis of emergency medical services, provided an application for emergency services is timely filed with the Division of Medicaid.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |104 Effective Month: December 2016 Mandatory Coverage of Infants and Children under Age 19 Coverage is mandatory for the following age-specific groups of children certified by the Division of Medicaid: • Infants to age 1 in households whose income is at or below 185% of the federal poverty level converted to a MAGI-equivalent standard. • Children age 1 to age 6 whose income is at or below 133% of the federal poverty level converted to a MAGI-equivalent standard. • Children age 6 to age 19 are eligible for Medicaid if household income is at or below 133% of the federal poverty level. This limit is not converted to a MAGI- equivalent because federal law specifies 133% as the maximum limit. Mandatory Coverage of Adoption Assistance and Foster Care Children Coverage is mandatory for children for whom adoption assistance or foster care maintenance payments are made under title IV-E of the Social Security Act, as determined by the Department of Child Protection Services who certifies eligibility for this group of children. Mandatory Coverage of Former Foster Care Children Coverage is mandatory for former foster care children who are under age twenty-six (26) if the child was in foster care and Medicaid upon reaching the age of 18 or prior to age 21 when released from foster care. Continued Medicaid coverage is certified by the Division of Medicaid in coordination with the Department of Child Protection Services.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |105 Effective Month: December 2016 101.02.02 MANDATORY CATEGORICALLY NEEDY - ABD The following are ABD coverage groups that must be covered, as required by federal law: Mandatory Coverage of SSI Recipients Coverage is mandatory for individuals receiving Supplemental Security Income (SSI) in Mississippi. This includes individuals receiving SSI pending a final determination of blindness or disability, those receiving SSI under an agreement to dispose of resources that exceed the SSI resource limit, and those receiving benefits under section 1619(a) or considered to be receiving SSI under 1619(b) of the Social Security Act. Coverage also includes those who would be eligible for SSI except for an eligibility requirement used in the SSI program that is specifically prohibited under title XIX. Eligibility for SSI is determined by the Social Security Administration. No separate application for Medicaid is required unless the individual needs to apply for retroactive Medicaid for up to three (3) months prior to the month of the SSI application, in which case the individual must apply with the Division of Medicaid for the retroactive period of eligibility. Mandatory Coverage of Certain Former SSI Recipients Certain former SSI recipients qualify for Medicaid to continue once their SSI terminates if the use of specific income disregards allows Medicaid eligibility. Medicaid eligibility is based on SSI income and resource limits. The Division of Medicaid certifies eligibility for all of the former SSI groups, as follows: • Cost of Living Individuals – these are former SSI recipients who become ineligible for SSI cash assistance as a result of a cost-of-living increase in title II benefits received after April, 1977. These individuals must be granted Medicaid coverage if the sole reason for the loss of SSI was an increase in RSDI benefits received by the individual and/or his or her financially responsible spouse. • Disabled Adult Children – these are former SSI recipients age 18 or over whose disability onset date was prior to turning age 22. SSI must have been paid at any time after July, 1987 and closed when title II benefits from a parent’s record began or increased, whichever caused the SSI to terminate. • Coverage is mandatory for certain disabled widows and widowers who would be eligible for SSI except for receipt of Social Security widow(er) benefits that terminated SSI. The individual must be age 50 through 64 and not eligible for Medicare in order to be evaluated for coverage under this provision.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |106 Effective Month: December 2016 Mandatory Coverage of Certain Medicare Cost-Sharing Groups The Division of Medicaid certifies eligibility for all of the Medicare cost-sharing groups: • Qualified Medicare Beneficiaries (QMB) must be entitled to Medicare Part A and have income that does not exceed 100% of the federal poverty level. Medical assistance is limited to payment of Medicare cost-sharing expenses that includes premiums, co-insurance and deductible charges. • Specified Low-Income Medicare Beneficiaries (SLMB) must be entitled to Medicare Part A and have income greater than 100% of the federal poverty level but less than 120% of the federal poverty level. Medical assistance for this group is limited to payment of Medicare Part B premiums. • Qualifying Individuals (QI) must be entitled to Medicare Part A and have income that is at least 120% of the federal poverty level but less than 135% of the federal poverty level. Medical assistance for this group is limited to payment of Medicare Part B premiums under a federal allotment of funds. Eligibility for coverage as a QI is dependent on the availability of federal funds. • Payment of the Medicare Part D pharmacy plan premium is applicable to the Medicare cost-sharing groups of QMB, SLMB and QI provided the beneficiary enrolls in a benchmark or $0 premium pharmacy plan. Benchmark plans are subject to change each calendar year based on plans that choose to participate within Mississippi. • Qualified Disabled and Working Individuals must be entitled to Medicare Part A and have income that does not exceed 200% of the federal poverty level whose return to work results in the loss of coverage for Medicare. Medical assistance is limited to payment of the Part A premium.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |107 Effective Month: December 2016 101.02.03 MANDATORY CATEGORICALLY NEEDY – SPECIAL GROUPS Mandatory Coverage of Certain Aliens for Emergency Services Emergency services, including labor and delivery services, must be provided to aliens who meet all eligibility requirements for Medicaid coverage in any MAGI- related or ABD coverage group except for their alien status who are in need of treatment of an emergency medical condition. Transplant services are prohibited. Coverage is limited to treatment of the emergency condition only. The Division of Medicaid certifies Medicaid coverage for Emergency Services for Aliens. Mandatory Presumptive Eligibility Determined by Qualified Hospitals Qualified hospitals must be allowed to determine presumptive eligibility for individuals eligible for Medicaid in certain Medicaid coverage groups, referred to as Hospital Presumptive Eligibility or HPE. HPE allows qualified hospitals to immediately enroll patients in Medicaid who are determined eligible for Medicaid by authorized hospital staff. HPE provides temporary Medicaid eligibility but also allows access to continuing Medicaid coverage provided the HPE decision includes filing a full Medicaid application.

Medicaid coverage groups eligible for HPE decisions include children up to age 19, pregnant women, low income parents or caretaker relative(s), former foster children and certain women with breast or cervical cancer. The Division of Medicaid is responsible for HPE Medicaid in conjunction with qualified hospitals that certify HPE eligibility.

Mandatory Coverage of Refugees Under the Refugee Resettlement Grant Medicaid is provided to certain refugees under a Refugee Resettlement Grant administered by the Department of Child Protection Services (DCPS). Refugees that meet the eligibility requirements for assistance under the grant are eligible for time limited Medicaid. DCPS certifies the eligibility for all qualified refugees that receive assistance and reimburses DOM with funds from the grant for all medical assistance provided by DOM to eligible refugees.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |108 Effective Month: December 2016 101.02.04 OPTIONAL CATEGORICALLY NEEDY – MAGI-RELATED Optional Coverage of Foster and Adoption Assistance Children The Department of Child Protection Services (DCPS) certifies eligibility for the following optional groups of children who are in the custody of DCPS: • Children under the age of 21 for whom the Department of Child Protection Services (DCPS) assumes full or partial financial responsibility who are in foster homes or private institutions are certified for Medicaid coverage by DCPS if the child’s income is within state established standards, converted to a MAGI- equivalent standard. • Children under age 21 in adoptions subsidized in full or part by DCPS and children in adoption assistance who cannot be placed for adoption without medical assistance due to special needs of the child are eligible for Medicaid regardless of the child’s income, as determined by DCPS. Optional Coverage of the Children’s Health Insurance Program (CHIP) The Division of Medicaid certifies eligibility for the Children’s Health Insurance Program (CHIP). Uninsured children under age 19 whose household income is at or below 200% of the federal poverty level converted to a MAGI-equivalent standard are covered by CHIP, which is a separate health plan. Covered children include: • Infants to age one (1) whose household income is between the MAGI equivalent standards of 185% - 200% of the federal poverty level; • Children age one (1) to age six (6) whose household income is between the MAGI-equivalent income standards of 133% - 200% of the federal poverty level; and, • Children age six (6) to age nineteen (19) whose household income is above 133% of the federal poverty level but below the MAGI-equivalent income standard of 200%.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |109 Effective Month: December 2016 Optional Waiver Coverage – Family Planning Section 1115 waiver coverage provides family planning and family planning related services to certain individuals who have family income at or below 185% of the federal poverty level converted to a MAGI-equivalent standard of federal poverty level. Waiver eligibility requirements include the following: • Women and men, ages 13 – 44, may qualify for waiver participation. • Waiver participants may not be otherwise eligible for Medicare, Medicaid, CHIP or other health insurance that includes coverage of family planning services. • Individuals who have had surgery to prevent reproduction cannot qualify for waiver participation, • MAGI non-filer household rules are applied to family income, excluding any non- taxable income sources. Applicants under the age of 19 are budgeted as a household of one with parental and other income disregarded. The Division of Medicaid determines eligibility for participation in the Family Planning Waiver.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |110 Effective Month: December 2016 101.02.05 OPTIONAL CATEGORICALLY NEEDY – ABD Optional Coverage of the Aged, Blind and Disabled Living At-Home The Division of Medicaid certifies eligibility in full or in part for the following groups of optional ABD groups: • Disabled individuals who work in excess of an established number of hours each month whose net family earned income is at or below 250% of the federal poverty level and whose unearned income is at or below 135% of the federal poverty level. Resource limits and other non-financial factors of eligibility are required. Premiums are payable for households with countable earnings that exceed 150% of the poverty level. • Women who have been screened for breast or cervical cancer under the Centers for Disease Control and Prevention Breast and Cervical Cancer Early Detection Program and need treatment for breast or cervical cancer, including a precancerous condition of the breast or cervix. Coverage is limited to women who are uninsured and are otherwise not eligible for Medicaid under any other mandatory coverage group and have not attained age 65. The MS State Department of Health is responsible for the screening, diagnosis and financial eligibility decisions; the Division of Medicaid is responsible for the non-financial eligibility decisions and for certifying Medicaid eligibility during the course of the woman’s active treatment. Optional Coverage of the Aged, Blind and Disabled Considered to be in an Institution • Individuals who would be eligible for cash assistance if not institutionalized. The individual must be in a title XIX nursing facility or hospital and meet income, resource and other non-financial factors of eligibility, as determined by the Division of Medicaid. • Individuals in institutions who are eligible under a special income test, including the use of an Income Trust, if applicable. The individual must be in a title XIX nursing facility or hospital and meet income, resource and other non-financial factors of eligibility, as determined by the Division of Medicaid. • Certain disabled children age 18 or under who are living at home, who would be eligible for Medicaid if in a medical institution and for whom the Division of Medicaid has made a determination as required under section 1902(e)(3)(B) of the Social Security Act.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |111 Effective Month: December 2016 Optional Waiver Coverage of Non-Medicare Aged, Blind and Disabled Individuals Section 1115 waiver coverage is granted to certain non-Medicare entitled individuals who are aged, blind or disabled and have income at or below 135% of the federal poverty level. Coverage under the waiver is subject to an enrollment cap. Resource limits and other factors of eligibility apply, as determined by the Division of Medicaid. Optional 1915 Waiver Coverage under Home & Community Based Services (HCBS) The following is a list of waiver coverage offered by the Division of Medicaid. Eligibility for waiver participation is determined in full or in part by the Division of Medicaid, as noted. Waiver participants receive full Medicaid coverage plus additional waiver services that allow the individual to remain in a private living arrangement rather than a medical institution. 1. Elderly and Disabled (E&D) Waiver – is operated by the Division of Medicaid. This HCBS waiver includes aged or disabled individuals age 21 or older whose level of care has been certified using a preadmission screening tool. The aged or disabled individual must be eligible as SSI or qualify under an income level that is equal to the Medicaid institutional limit. Institutional income and resource limits and rules apply, including the use of an Income Trust to qualify for coverage. A waiver participant may not reside in a nursing facility or personal care home. The Division of Medicaid certifies eligibility for individuals who do not receive SSI. 2. Independent Living (IL) Waiver – is operated jointly by the Division of Medicaid and the MS Department of Rehabilitation Services. Eligibility is limited to individuals age 16 or older who exhibit severe orthopedic and/or neurological impairments. Clinical eligibility for waiver services is determined through a preadmission screening tool. An individual can participate in the IL waiver and be eligible as SSI, a Disabled Child Living At-Home, a Disabled Adult Child, a Working Disabled recipient or be eligible in a MAGI-related category or adoption assistance or foster child category of eligibility provided clinical waiver criteria is met. If an individual is not eligible in an allowed category, the individual may be determined eligible using institutional income and resource eligibility rules and limits, including the use of an Income Trust to qualify for coverage. The Division of Medicaid certifies eligibility for individuals who do not receive SSI or foster care/adoption assistance Medicaid through Child Protection Services.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |112 Effective Month: December 2016 Optional 1915 Waiver Coverage under Home & Community Based Services (HCBS) (Continued) 3. Assisted Living (AL) Waiver – is operated by the Division of Medicaid. This HCBS waiver includes aged, blind or disabled individuals age 21 or over whose level of care has been certified by a preadmission screening tool. The individual must be eligible as SSI or qualify under the Medicaid institutional income limit. Institutional income and resource limits and rules apply, including the use of an Income Trust to qualify for coverage. Participants must reside in AL facilities that are approved to participate in the AL waiver. 4. Traumatic Brain Injury/Spinal Cord Injury (TBI/SCI) Waiver – is operated jointly by the Division of Medicaid and the MS Department of Rehabilitation Services. TBI’s and SCI’s must meet certain conditions specified by the waiver and the extent of the injury must be certified by a physician. An individual can participate in the IL waiver and be eligible as SSI, a Disabled Child Living At- Home, a Disabled Adult Child, a Working Disabled recipient or be eligible in a MAGI-related category or adoption assistance or foster child category of eligibility provided clinical waiver criteria is met. If an individual is not eligible in an allowed category, the individual may be determined eligible by the Division of Medicaid using institutional income and resource eligibility rules and limits, including the use of an Income Trust to qualify for coverage. The Division of Medicaid certifies eligibility for individuals who do not receive SSI or foster care/adoption assistance Medicaid through Child Protection Services. 5. Intellectual Disabilities/Developmental Disabilities (ID/DD) Waiver – is operated jointly with the MS Department of Mental Health as an alternative to institutionalization in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID). This HCBS waiver carries no age restrictions and includes individuals eligible as SSI, a Disabled Child Living At-Home, a Disabled Adult Child, a Working Disabled recipient or eligible in a MAGI-related category or adoption assistance or foster child category of eligibility provided clinical waiver criteria is met. If an individual is not eligible in an allowed category, the individual may be determined eligible by the Division of Medicaid using institutional income and resource eligibility rules and limits, including the use of an Income Trust to qualify for coverage. The Division of Medicaid certifies eligibility for individuals who do not receive SSI or foster care/adoption assistance Medicaid through Child Protection Services.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |113 Effective Month: December 2016 Intellectual Disabilities/Developmental Disabilities (ID/DD) Waiver (Continued)

The Division of Medicaid offers 1915(i) State Plan services to individuals with an

intellectual and/or developmental disability that are in need of the services

offered under 1915(i), specifically; day habilitation services, prevocational

services and supported employment services. If a Medicaid recipient in a full

services at-home category of eligibility has the clinical qualifications needed, the

recipient can qualify for 1915(i) services without being placed on the ID/DD

waiver program provided their income does not exceed 150% of the federal

poverty level. Individuals enrolled in a Medicare cost-sharing group (QMB,

SLMB or QI) or recipients in a full service COE with income above 150% FPL

can qualify for the 1915(i) services only by qualifying for the ID/DD waiver,

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |200

Effective Month: December 2016 101.03 HOW TO APPLY This chapter provides guidelines on the process of applying for eligibility determinations for all coverage groups. 101.03.01 APPLICANT An applicant is someone whose signed application form has been received by the Division of Medicaid (DOM) and is requesting an eligibility determination. An applicant is also someone whose signed application is received by another agency or entity authorized to make Medicaid certifications. An applicant includes someone who applies for coverage in MS through the Federally Facilitated Marketplace (FFM) and has their electronic application information transferred to DOM via a process referred to as an Account Transfer (AT). 101.03.01A Deceased Applicants An application for Medicaid may be made on behalf of a deceased individual. The application must be filed before the end of the third month following the date of death in order for DOM to be able to consider the month of death for coverage, using the rules that apply for retroactive Medicaid. 101.03.01B Non-Applicants This is an individual who is not requesting an eligibility determination for himself or herself but is included in the applicant’s household to determine eligibility for the applicant. 101.03.02 DOM APPLICATION FORM(S) DOM uses two types of application forms to determine eligibility: • For MAGI-related purposes, the Mississippi Application for Health Benefits is the single streamlined application form used to apply for Medicaid and CHIP. Information from this form is also used to refer individuals to the FFM for health coverage if ineligible for health coverage through DOM.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |201

Effective Month: December 2016 DOM APPLICATION FORMS (Continued) • For ABD purposes, the Application for Mississippi Medicaid Aged, Blind and Disabled Medicaid Programs is used. • The MAGI-related and ABD applications forms may be a paper version, an electronic version or an exact facsimile of the appropriate form. • Applications filed for Medicaid coverage through other agencies or entities have their own Medicaid applications, such as SSI or HPE. The application form is a legal document, completed by the applicant or representative that signifies intent to apply and: • Is the official agency document used to collect information necessary to determine eligibility; • Is the applicant’s formal declaration of financial and other circumstances at the time of application; • Is the applicant’s certification that all information provided is true and correct; • Provides notice to the applicant of his rights and responsibilities; and • May be introduced as evidence in a court of law. 101.03.03 SIGNATURE REQUIREMENTS An application form must be signed to be considered a valid application. The signature does not have to be an original signature since applications are allowed to be submitted via means other than on an original paper form; however, a valid signature by someone authorized to apply for Medicaid or CHIP is required. Signed and unsigned applications are treated differently, as specified below. If an applicant is unable to write his/her name, the form may be signed with an “X” mark; however, a witness signature is required. If an applicant is incompetent (adjudged by a court) or incapacitated (due to a physical or mental condition), these conditions require that someone be named to officially represent the applicant, as addressed in “Representatives Authorized to Act for an Applicant.”

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |202

Effective Month: December 2016 SIGNATURE REQUIREMENTS (Continued) • Unsigned applications and/or applications signed with a mark that are not witnessed must be returned to the applicant with an explanation of the signature requirements. An unsigned application or an “X” marked application that has not been witnessed is not valid. • Applications that are signed but are incomplete are accepted as valid applications. The Specialist will work with the applicant to complete the information needed. • Applications that are signed by an individual other than a person who is authorized to apply, as specified in “Who Can File” below, are accepted as valid applications. The Specialist must work with the applicant or head of household to obtain an acceptable signature on the submitted application form.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |203

Effective Month: December 2016 101.03.04 REPRESENTATIVES AUTHORIZED TO ACT FOR AN APPLICANT There are three (3) types of representatives allowed to act in behalf of an applicant or recipient in filing an application for health coverage through DOM: 1. Authorized Representative An authorized representative is a person or employee of an organization who is acting responsibly for the applicant with his knowledge and written consent. The MAGI-related application form allows the head of household to designate an authorized representative with no separate written authorization required except in cases where the head of household has a legal representative who is required to act on his/her behalf. ABD applications require the use of a separate authorization form (DOM-302A) in order for an applicant or recipient to appoint an authorized representative. The authorized representative has knowledge of the applicant’s circumstances and is usually a relative or close friend, but may be a designee of an organization if the applicant or recipient permits. The authorized representative must be authorized in writing by the applicant to act on his behalf. The application is filed in the name of the applicant. The authorized representative can provide eligibility information, and sign the application form and receive all eligibility notices; however, the applicant or recipient has the right to limit the authority of their authorized representative. The appointment of an authorized representative does not prevent the Division of Medicaid from communicating directly with the applicant or recipient as deemed appropriate. NOTE: In instances where the applicant or recipient designates an authorized representative but places a limit on the receipt of notices by the representative, maintain the authorized representative information in the case record rather than entering the representative information in the system. If representative information is entered into the system, the representative will receive all letters and notices issued by the system. When an organization or other individual assisted with the completion of an application and their primary need is access to case record information rather than function as a case representative, completion of the “Authorization for the Use/Disclosure of Protected Health Information” form may be more appropriate to allow access to information while the applicant or recipient represents themselves. Contact with the applicant or recipient is needed to make this determination, which must be documented in the case record.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |204

Effective Month: December 2016 2. Self-Designated Representative

A self-designated representative is a person acting responsibly for an applicant

or recipient because the physical or mental condition of the applicant/recipient

is such that he cannot authorize anyone to act for him nor can he act for himself.

Family members or non-relatives with knowledge of the applicant’s or

recipient’s circumstances are allowed to self-designate in writing with the use of

a form designed for this purpose (DOM-302B). A representative of an

organization or a provider cannot self-designate to represent an applicant or

recipient, except in cases where the self-designating individual is an owner,

operator or employee of a state-owned long term care healthcare facility. All

other individuals representing an organization or provider must become legally

appointed to represent an individual for health care decisions, in which case the

individual becomes the Legal Representative of the applicant or recipient.

A self-designated representative must file an application or review form in the

name of the applicant/recipient with the self-designated representative

providing required information to determine or re-determine eligibility and sign

all eligibility-related forms that are required. The self-designated representative

will receive all eligibility notices and letters.

NOTE: A parent or primary caretaker relative is allowed to apply for a child

without signing the self-designation form authorizing themselves as a

representative. 3. Legal Representative A legal representative is someone who has been legally appointed to act on behalf of an applicant or representative. The legal representative must provide documentation of their legal authorization to act for the applicant or recipient, such as a Power of Attorney document, legal guardianship decree, conservatorship decree, a custody decree or other type of court order, and complete a Legal Representative form (DOM-302C). All such documents must specify that the legally appointed individual has the right to make health care decisions for the applicant or recipient. If an applicant or recipient is deceased, proof that the individual is the executor or administrator of the applicant’s or recipient’s estate is required if eligibility is needed in the month of death and/or retroactive period. The legally appointed representative will act in behalf of the applicant or recipient in all matters with the Division of Medicaid without limitation.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |205

Effective Month: December 2016 101.03.05 WHO CAN FILE THE APPLICATION An application can be filed by one of the following individuals, as applicable to the case: • Adult applicants; • Certain minor applicants, including; o A pregnant minor of any age requesting coverage solely due to pregnancy; or o A married minor living with a spouse; or o A minor living independently; or o A minor living with his/her parents and applying only for the minor’s own children. • The parent who has primary physical custody of a minor child; • Either parent of a minor child when physical custody is equally divided between legal parents; • The caretaker relative with whom a dependent child is living who has primary responsibility for the child’s care. o A caretaker relative is a relative by blood, adoption or marriage with whom the child is living who assumes primary responsibility for the child’s care. o A dependent child is under the age of 18 and deprived of parental support by reason of death, absence from the home or physical or mental incapacity. • An authorized representative designated in writing by the applicant on the MAGI application or on DOM-302A, Authorized Representative Form, for ABD; • A self-designated representative who signs the appropriate DOM-302B, Self- Designated Representative Form, allowing self-designation. • A legal representative with the authority to make healthcare decisions for the applicant who has completed Form 302C, Legal Representative Form. •

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |206

Effective Month: January 2019 WHO CAN FILE THE APPLICATION (Continued) An application signed by anyone other than a person described above will be accepted, but a signature of a person authorized to apply must be obtained during the application process. 101.03.06 ACCESS AND ACCOMMODATION IN APPLYING Access to a regional office or out-stationed site should not be a barrier for individuals wishing to apply in person or request assistance with the application process. Each office where Medicaid Specialists are located must be accessible for handicapped persons. If a site is not accessible, make alternate accommodations, including assistance with an alternative method of filing the application. Each application intake site and each telephone application is required to accommodate: • Individuals with limited English proficiency, i.e., individuals who are unable to communicate effectively in any language other than his native language. When interpreter services are needed, use DOM’s language and document translation service to secure the assistance of an interpreter capable of communicating in the applicant’s language to assist in the application process and relate the services offered. This service is available free of charge and is available to applicants and those inquiring about coverage or services offered through DOM. The individual’s privacy must always be protected during such calls. It is not permissible to require an applicant to provide his/her own interpreter or rely on an accompanying adult or minor child of the applicant to provide interpreter services unless it is an emergency situation involving imminent threat of safety or welfare of the applicant or recipient or person inquiring and no qualified interpreter is available. However, if the applicant, recipient or individual inquiring about Medicaid requests an accompanying adult to interpret and the adult agrees and reliance on the adult is appropriate to the circumstances, DOM may allow the adult to provide interpreter services. • Blind applicants by reading forms in their entirety, assist in completion of the forms, explain various program requirements and services offered through the agency and answer any questions the applicant may ask.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |207

Effective Month: December 2016 ACCESS AND ACCOMMODATION IN APPLYING (Continued) • Deaf applicants by securing a person proficient in sign language when needed or communicate in writing to relate an explanation of program requirements and services offered through the agency and to answer questions. • Individuals who cannot read and/or write by reading forms in their entirety, assist in completion of the forms, explain various program requirements and services offered through the agency and answer any questions the applicant may ask.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |208

Effective Month: December 2016 101.03.07 REASONABLE EFFORTS TO ASSIST The Regional and Central Office of DOM is expected to: • Provide orderly surroundings to persons who come to the office; • Provide courteous service to all persons who come to or contact the office; • Provide the appropriate application form to anyone who requests one; • Allow any individual the right to apply for any benefits, regardless of circumstances. This includes allowing a clearly ineligible individual to apply; • Communicate in a clear and courteous manner information regarding programs and services offered through DOM; • Determine as soon as possible if the person asking for help is seeking a type of assistance which the agency offers. If the individual is not requesting a type of assistance offered by the regional office, he should be referred to another community agency or resource to meet his needs, if one is available.

In addition, it is required that Medicaid Specialists make reasonable efforts to assist all applicants in order to have the applicant’s eligibility determined and/or re-determined. Assistance includes, but is not limited to, the following: • Help with forms completion; • Help with securing a representative, if needed; • Help in obtaining necessary information from third parties; and • Providing information that will assist the applicant in making informed decisions about Medicaid eligibility. Medicaid program policies are public information. Each applicant has a right to know the policies that will impact his eligibility. MAGI and/or ABD applicants who ask for assistance or are not capable of handling the application process and have no available family member or friend capable of assisting or have representatives who do not act responsibly for a MAGI or ABD applicant require special handling. Otherwise, the application will result in multiple denials that must be avoided if agency intervention is needed to resolve a failure to comply with application or renewal processing. Action needed is as follows:

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |209

Effective Month: December 2016 REASONABLE EFFORTS TO ASSIST (Continued) • If the application is for long term care in a nursing facility, the Specialist assigned to the nursing facility should contact the facility to let appropriate staff know that the application cannot proceed because the representative is not cooperating or the applicant is not capable. If the facility is a state-owned or operated facility, the administrator or his/her designee can act as a self-designated representative if there is no available family member that can become the representative. For privately owned facilities, the administrator has the right to become the legal representative to act for the applicant unless another family member is available. If the administrator is willing to become the legal representative, pend the case until the legal authority can be obtained. If the applicant already has a court-appointed legal representative, the nursing facility (or other available family member) has the right to approach the court to have a non-cooperating legal representative removed and replaced with someone willing to act responsibly. • If the application or review is for an at-home ABD or MAGI-related case, the Specialist must speak with the applicant to determine if there is a family member or close friend or neighbor that would be willing to assist the individual in becoming an authorized representative in order to secure any needed verifications. • If an applicant (MAGI or ABD, at home or in long term care) already has a legal representative appointed as Power of Attorney but the individual is not cooperating in the application process, the Specialist should discuss this matter with other available family members who may be willing to secure Power of Attorney. The most recently appointed Power of Attorney with the right to make healthcare decisions for the applicant will be the one with the authority to act for the applicant. • If any of the above situations does not address or remedy a situation where an applicant/recipient is incapable or unable to provide needed information and there is either no representative or there is an irresponsible representative who is not acting in the applicant’s best interest, the Specialist must discuss the situation with their supervisor who should seek assistance from their central office contact.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |225

Effective Month: December 2016 101.04 FILING THE APPLICATION Individuals inquiring about program eligibility requirements should be informed of their opportunity to apply and informed about the various means of applying. If a hardcopy application is requested, the regional office must provide an application to the individual or mail it, as applicable. If another person or agency refers the name of an individual in need of medical assistance to the regional office, the individual will be contacted, if possible, and the various means of applying explained. Otherwise, an application will be mailed if an address is available. 101.04.01 RIGHT TO APPLY Individuals wishing to file an application must be afforded the opportunity to do so without delay. When an individual inquires about making an application at any regional office, an application form must be provided and the person offered the opportunity to file that day. The agency must allow an individual or individuals of an applicant’s choice to accompany and assist an applicant or recipient in the application or redetermination process; however, in order to officially represent the applicant or recipient, an individual must become an authorized, self-designated or legal representative. Refer to 101.03.04 for a discussion of authorized representatives and individuals or organizations needing access to case information, in which case the HIPAA release form may be more appropriate. 101.04.02 REQUEST FOR AN INFORMAL MEDICAID ELIGIBILITY OPINION An individual seeking assistance from other social service agencies may be required to obtain a statement from DOM advising that he is not eligible for Medicaid in order to obtain that agency’s services. If the individual indicates through questioning that none of the categorical requirements would be met, i.e., the person is not aged, blind, disabled, pregnant, under age 19 or part of a family with dependent children, the regional office may provide the individual with a statement that he is not eligible based on the self-declared information. The statement must also explain to the individual that the decision is not an official denial and cannot be appealed. If an official denial notice is required, an application must be filed and a decision rendered after all eligibility factors have been examined according to policy. The “Request for Unofficial Denial” form is located in the Appendix page by the same name and must be used to issue an unofficial denial of eligibility.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |226

Effective Month: December 2016 101.04.03 SUBMITTING AN APPLICATION AND APPLICATION FILE DATE An application for Medicaid may be filed in any of the following described submission methods. The application file date is the date a valid application form is received by the agency: • In person in any regional office, official out-stationed location or other location outside the regional office where eligibility staff are on official duty, such as a nursing home, hospital or other public facility. The filing date is the date received by the office or other location; • By mail in any regional office - o Applications received by mail which arrive after the end of the month, but were postmarked by the last day of the month will be considered to have been received by the regional office on the last day of the month in which they are postmarked. • By fax in any regional office. The filing date is the date received by the agency (central or regional office, whichever office first receives the application). An original signature is not required, • By on-line submission of the application to DOM. The filing date is the date received by the agency (central or regional office). An electronic signature is accepted for applications filed on-line with the agency. • By on-line submission of the application to the Federally Facilitated Marketplace (FFM), which is then transferred to DOM. The filing date is the date the application is received by the FFM. An electronic signature is accepted for applications filed on-line to the FFM. • By telephone via a telephonically recorded application process. The date of filing is the date the telephonic signature is recorded, which should be the date of the telephone interview. Telephone applications are conducted by central office staff completing the appropriate paper application based on applicant statements that are recorded, including the telephonic signature. When the application interview is concluded, the completed application form is forwarded to the appropriate regional office for processing. A request for a telephonic application received by a regional office must be referred to the central office in order for the interview to be recorded. Upon referral, central office staff will coordinate the telephone interview with the applicant.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |227

Effective Month: December 2016 SUBMITTING AN APPLICATION AND APPLICATION FILE DATE (Continued) ABD telephone applications may be accepted by a regional office when circumstances prevent the applicant from applying or being interviewed in any other manner. The date of the telephone interview is the date of filing. The application must be mailed to the individual to sign and return in order for the agency to have a completed application acknowledged by the applicant.

Once a signed and dated application has been received by the agency, it must not be altered by adding, changing or deleting any information. During an interview, an applicant may make changes to the information on an application. If the interview is in-person, the applicant must initial the changes. If the change to information on the application is reported in any other manner, it must be documented in the case record and/or in the case narrative, but not on the application form.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |228

Effective Month: December 2016 101.04.04 PROTECTED APPLICATION DATES FOR MEDICAID APPLICANTS An applicant who applies for Medicaid on any basis is entitled to have eligibility determined under all available coverage groups. Therefore, an individual who files a MAGI-related application does not also have to file an ABD application to be evaluated for potential eligibility in an ABD program and vice versa. Any application received by the regional office must be evaluated across program lines to determine if eligibility exists under any category of Medicaid coverage. For example, a MAGI-related application indicates an applying household member is disabled. If the disabled member of the household is not eligible in a MAGI- related category, an ABD application would be issued as a supplemental form as outlined in 101.09, Combination MAGI and ABD Applications. The MAGI- related application date is the protected filing date. This also includes applications filed through another certifying agency, such as the Social Security Administration (for SSI applicants). If an individual is denied SSI, but would qualify in any available Medicaid-only coverage group, the regional office is required to use the SSI application date as the protected filing date for Medicaid benefits. If the individual is eligible for Medicaid-only, the regional office must determine eligibility using the SSI application date as the Medicaid application date. Additional information may be needed to determine eligibility; however, the application date is the SSI application date and the case must be documented to reflect this. 101.04.05 APPLICATIONS RECEIVED FROM MS RESIDENTS OUT-OF-STATE Applications made for Mississippi residents who are temporarily out of the state may be accepted. Generally the applicant must return to the state before the application processing period ends. However, the application of someone who is hospitalized in another state and planning to return to Mississippi when discharged may be processed in the usual manner. If the application is approved, the Specialist must review eligibility every three (3) months to determine the individual’s continued intent to reside in MS.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |229

Effective Month: December 2016 101.04.06 OUT OF STATE APPLICANTS Applications received from persons residing in another state will be denied and notice mailed to explain that the applicants will need to reapply upon arrival in MS with intent to reside. Persons who are in MS for a temporary purpose, such as a visit, who intend to return to their home out of state are not eligible for Mississippi Medicaid or CHIP. However, applicants must always be given the right to make an application if they wish to do so and receive a decision on their case. 101.04.07 RESIDENCE CHANGE DURING THE APPLICATION PROCESS If the applicant reports moving to another location within the state during the application process, the application must be completed by the first regional office, and if approved, transferred to the new location. If the application is denied, do not transfer the record until the person reapplies in the second location. If the applicant reports moving out of the state during the application process, determine when the move occurred. If otherwise eligible, the applicant may be approved for Medicaid for any requested retroactive months through the month of the move. If the applicant would be CHIP-eligible, determine if eligibility can be established for the month of application or any subsequent month(s) when the applicant lived in MS. NOTE: If only some members of the applicant family are moving from the state, identify the adults and/or children who remain MS residents and handle their ongoing eligibility accordingly. 101.04.08 WHERE TO FILE THE APPLICATION Applications should be filed with or directed to the regional office that serves the applicant’s county of residence. However, applications for individuals living in another RO’s service area must be accepted by any regional office. The regional office must review each application upon receipt and confirm the accuracy of the address if there is a question about the responsible office. The following guidelines should be followed based on the appropriate situation:

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |230

Effective Month: December 2016 WHERE TO FILE THE APPLICATION (Continued) Application Filed with Correct RO

Date stamp the form if received or copied into hardcopy form; Register the application within 48 hours (certain applications are auto-registered, such as Account Transfers from the FFM or LIS applications from SSA). If ABD application received in- person, conduct interview, if required; If interview cannot take place, or if application received by mail or electronically, schedule required interview in writing within 10 calendar days of receipt of application. MAGI applicants applying in person must be offered assistance, if requested. Application Filed with Incorrect RO Accept the application and date stamp; Do not register the application; Mail or fax the application and any other documents provided or copied to the correct RO within 24 hours. The correct RO must register within 48 hours. The application date is the date received by the “incorrect” RO. If registered by the incorrect RO, or if application is not mailed timely to the correct RO (by end of 2nd working day following receipt), the “incorrect” RO will register and complete the application. If ABD application received in- person, conduct interview, if required; offer assistance to MAGI applicants, if requested. Make copies of any documents provided in- person; inform applicant of correct RO that will handle case. Application completed by incorrect RO will be transferred to correct RO; Applicant will be notified of the correct RO that will handle future reviews.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |231

Effective Month: December 2016

Combination ABD/MAGI Households Combination ABD/MAGI households are defined as cases in which there is both an ABD applicant or recipient living in the same household as MAGI applicants or recipients. ABD and MAGI individuals living in the same household are treated as one case in the system and one physical record is created, with the person designated as the head of household as the primary case head. The regional office that serves the household’s county of residence is the office responsible for the ABD/MAGI members, regardless of where the application is filed or whether the ABD and MAGI applications are filed at the same time or separately. If an ABD applicant/recipient is institutionalized which causes other ABD/MAGI applicants or recipients to live apart from the institutionalized individual but the household remains bound by relationship (marriage, parent/child), two separate cases are set up in the system; one for the at-home household members and one for the institutionalized member. One physical case record is established with the person who is the head of household of the ABD institutionalized case as the primary case head. The regional office that serves the county where the nursing facility is located is responsible for both ABD and MAGI records. Applications Filed With the Federally Facilitated Marketplace (FFM) Applications for MAGI-related Medicaid or CHIP may also be filed on-line with the Federally Facilitated Marketplace or FFM. The FFM is also referred to as the health insurance exchange. An FFM operates in states that choose not to build their own state-operated exchange. The FFM for MS determines eligibility for enrollment in qualified health plans and insurance affordability programs and assists in determining eligibility for Medicaid and CHIP by verifying certain application information through a Data Services Hub. If an individual or family appears to be eligible for Medicaid or CHIP based on Hub verified data, the FFM transfers the electronic account, referred to as an Account Transfer, to MS for completion of the application. • An individual who applies for Medicaid coverage in MS through the FFM has their electronic application information transferred to DOM via a process referred to as an Account Transfer (AT).

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |232

Effective Month: December 2016

Applications Filed With the Federally Facilitated Marketplace (FFM) (Continued) • AT’s received from the FFM are evaluated for MAGI-related coverage initially but if any household member indicates on the AT that a disability exists or if the individual is aged, that household member is evaluated for ABD coverage. • The “insurance affordability program” referenced above is a term that includes Medicaid, CHIP and coverage in a qualified health plan through the FFM that provides advance payments of a premium tax credit or cost-sharing reductions to qualified individuals. • MAGI-related denials that do not indicate possible ABD eligibility are automatically referred to the FFM for an evaluation of coverage in other insurance affordability programs. Non-Medicare ABD denials are also referred to the FFM for an evaluation of coverage. NOTE: Referrals to the FFM are made upon denial provided the application is not denied for administrative reasons, such as, failure to comply with application requirements, voluntary withdrawal or any other denial due to failure to complete the application process.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |233

Effective Month: December 2016

101.04.09 VOTER REGISTRATION The National Voter Registration Act (NVRA) requires the Division of Medicaid, as a public assistance agency, to offer the opportunity to register to vote or update voter registration to applicants, recipients and adults applying for children at the time of application and at review and whenever an address change is reported. Each regional office must ensure the voter registration form entitled, “Mississippi Mail-In and NVRA Agency Voter Registration Application” form are included with application forms mailed or given out for an applicant to complete, and available during in-person interviews within the office and at out- stationed sites. Voter registration forms are also available on-line for applicants applying on line. Voter registration forms must also be offered to individuals applying by telephone. Assistance with completion of the forms must be offered and provided unless assistance is refused. It is not required for the agency to offer voter registration forms/assistance to a representative of an adult. The MAGI-related application form asks if the applicant wants to register to vote. The ABD application form refers the applicant to their worker if the applicant wants to register to vote or update their voter registration information. Responses to these questions are entered into the system for reporting purposes. Voter registration forms completed and returned to the regional office must be logged on the appropriate form and transmitted to the appropriate county Circuit Clerk’s office with 5 business days of receipt. Form received within 5 days of the voter registration deadline must be transmitted daily. The agency offers voter registration training for new employees and existing employees are trained in the specifics of voter registration responsibilities semi- annually.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |250 Effective Month: December 2016 101.05 MEDICAID APPLICATIONS FILED THROUGH ANOTHER AGENCY OR ENTITY Certain applications for Medicaid are filed through other agencies or entities. Currently, these include the following types of applications that are discussed in further detail below. • SSI applications. SSI applicants approved for SSI are automatically eligible for Medicaid with no separate application for Medicaid required unless retroactive Medicaid is needed or there are missing months of SSI eligibility that need to be evaluated for Medicaid-only eligibility to fill in gaps of ineligibility for SSI. In addition, SSI recipients entering long term care in a nursing facility, ICF/IID or PRTF require DOM authorization of a Medicaid per diem payment to the facility. • Children under age 21 who are in the custody of the Department of Child Protection Services (DCPS) and who are certified as Medicaid eligible by the DCPS. Foster children and adoption assistance children determined eligible for Medicaid by DCPS require no separate application. If the individual enters a nursing facility, ICF/IID or PRTF, DOM must authorize the Medicaid per diem payment to the facility. • Applications filed with the FFM and transferred to the Division of Medicaid as Account Transfers (AT’s). Referrals from the FFM require a decision to approve or deny eligibility for Medicaid or CHIP from DOM. • LIS (Low-Income Subsidy) applications filed as part of an application for Medicare coverage through the Social Security Administration (SSA). LIS applications are applications whose eligibility is limited to one of the Medicare cost-sharing coverage groups (QMB, SLMB or QI) and require a DOM decision to approve or deny eligibility. • Hospital Presumptive Eligibility (HPE) applications processed by qualified hospitals in order to certify and place time-limited Medicaid eligibility on file for individuals qualifying for HPE. HPE eligibility is determined by qualified hospital staff.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |251 Effective Month: December 2016 101.05.01 APPLICATIONS FOR SSI APPLICANTS SSI applicants who file an application with SSA will automatically receive Medicaid for months SSI is approved. A systems-generated notice of Medicaid approval is issued by DOM providing the beginning date of SSI/Medicaid eligibility and informing the SSI recipient that retroactive Medicaid is available. The notice provides the name, address and phone number of the Medicaid Regional Office where a retroactive Medicaid application may be filed. This notice is separate from the SSI notice of approval. SSI applicants who are denied SSI receive a systems-generated notice of Medicaid denial issued by DOM explaining that although SSI/Medicaid is denied, eligibility for Medicaid-only is available. The various ABD coverage groups are described in the notice and so is the availability of retroactive Medicaid. The notice provides the name, address and phone number of the Medicaid Regional Office where a retroactive Medicaid and/or Medicaid-only application may be filed. This notice is separate from the SSI notice of denial. An SSI applicant may apply for SSI and for Medicaid-only with DOM on the same date or for the same time period. When an application is filed for both SSI and for Medicaid-only, a decision is required by DOM on the Medicaid application. It is not appropriate to hold the application while waiting on the SSI decision nor is it appropriate to deny the application because the applicant has an application pending with SSA. If retroactive Medicaid is requested, a Medicaid decision on the retroactive month(s) is required regardless of whether the SSI application is approved or denied. Follow policy outlined in 101.10.06 for SSI Eligibles requesting retroactive Medicaid and/or eligibility for missing month(s) of SSI eligibility. Follow policy outlined in 500.10.01 for SSI Eligibles entering Long Term Care who need the LTC per diem payment authorized by DOM.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |252 Effective Month: December 2016 101.05.02 APPLICATIONS FOR FOSTER CHILDREN AND ADOPTION ASSISTANCE CHILDREN CERTIFIED BY THE DEPARTMENT OF CHILD PROTECTION SERVICES (DCPS) Children who qualify for Medicaid while in the custody of DCPS are certified as Medicaid-eligible by DCPS, including any retroactive months. However, not all children in the custody of DCPS are eligible for DCPS-related Medicaid, usually because the child has income (or resources) of their own that exceeds the limit(s) allowed by DCPS. If a child is not Medicaid eligible through the DCPS, the county Social Worker or foster parent will apply for Medicaid for the child through the Medicaid Regional Office and the RO will handle as a MAGI-related application, unless the child applies on the basis of disability and ABD Medicaid is requested. Follow policy outlined in 500.10.02 for foster children or adoption assistance children certified as eligible by DCPS entering Long Term Care who need the LTC per diem payment authorized by DOM. 101.05.03 ACCOUNT TRANSFERS (AT’S) RECEIVED FROM THE FFM Individuals who apply for health coverage through the FFM are assessed for Medicaid and CHIP eligibility and health coverage through the FFM. If some or all household members appear to be Medicaid or CHIP eligible, the electronic accounts for those household members are transferred to DOM. If some or all household members are not eligible for Medicaid or CHIP but are eligible for health coverage through the FFM through a participating health insurer, those individuals are enrolled in a Qualified Health Plan (QHP) by the FFM. Individuals who are enrolled in a QHP with income between 100% - 400% of the FPL based on family size can qualify for premium credits to purchase insurance or for cost-sharing subsidies that reduce annual cost-sharing expenses of the insurance purchased through the FFM. Individuals referred for Medicaid or CHIP coverage are first evaluated by the system to determine the following:

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |253 Effective Month: December 2016 ACCOUNT TRANSFERS (AT’S) RECEIVED FROM THE FFM (Continued) • If there is sufficient information on the AT file to identify household members and confirm that applying household members are not currently eligible in any active case, the case is auto-registered in the system as a pending application. Sufficient information includes a SSN for all applying. • If a household member or entire case is closed in the system, the individual or case will have an application contact opened so that an application can be processed for the applying household members. • If an AT lacks sufficient identifying information to auto-register an application or redetermination contact, the AT defaults to a pdf document on Report RJ541B. This report is used by the regional office to register the application in the system. The regional office assigned the AT will complete the application in the same manner as an application received by DOM. A case record is created with the information obtained during the AT application process, if needed. If all information is available electronically, no paper record is required. 101.05.04 LOW INCOME SUBSIDY (LIS) APPLICATIONS RECEIVED FROM SSA For individuals who apply for the Low-Income Subsidy (LIS) with the Social Security Administration (SSA), the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) requires SSA to forward an electronic application to the state Medicaid agency to determine if the individual is eligible in a Medicare Savings Program (referred to by DOM as Medicare Cost-Sharing programs, consisting of QMB, SLMB and QI). An individual indicates their desire to apply for eligibility to be determined under the Medicare cost-sharing programs when applying for Medicare and/or Social Security benefits and checking “yes” to the question that asks about applying for “Extra Help” in paying for Medicare expenses. Electronic applications are received daily from SSA.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |254 Effective Month: December 2016

LOW INCOME SUBSIDY (LIS) APPLICATIONS RECEIVED FROM SSA (Continued) When the electronic application is received by DOM, the following occurs: • The system checks the recipient file to determine if the individual is currently eligible for Medicaid. If the individual is eligible, the LIS application is placed on a report in Reports On-Line that indicates the LIS application was not registered because the individual was eligible for Medicaid. • If the individual is not currently eligible, the system registers a pending LIS application. • Each regional office must complete their assigned LIS applications by first reviewing the information submitted by SSA on the LIS file and SVES to determine if the application can be approved based on available information. If it is possible to make a decision, the LIS application is approved or denied accordingly. • If additional information is needed to make a decision on income eligibility, issue applicable Request(s) for Information to secure the needed verification to approve or deny the LIS application.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |255 Effective Month: December 2016

101.05.05 HOSPITAL PRESUMPTIVE ELIGIBILTY (HPE) Qualified hospitals are allowed to make presumptive eligibility decisions prior to a formal determination of Medicaid eligibility by the Division of Medicaid. A qualified hospital is one that participates as a Medicaid provider, has executed required HPE formal agreements with DOM and agrees to make HPE decisions according to state policies provided to authorized hospital staff. HPE is time- limited Medicaid eligibility for certain children, pregnant women, parents or caretakers presumed to be eligible for Medicaid. DOM provides qualified hospitals with the HPE application form and model notices to use to establish HPE. The hospital must provide written notice to the HPE applicant regarding their eligibility for HPE and assist the HPE applicant in completing and submitting the full application for Medicaid before the end of the HPE period. The Division of Medicaid provides training and training material to hospital staff assigned to HPE. These individuals are required to pass a knowledge test before becoming certified to authorize HPE decisions. In addition, DOM provides the HPE staff with HPE applications and notices for use in HPE decisions. HPE approvals must be transmitted by the qualified hospital to DOM central office staff assigned to HPE within 5 days after the approval decision. DOM assigns a Medicaid ID and places HPE on file. The begin date of HPE is the day the hospital approves HPE. The end date of HPE is either the last day of the month following the month the HPE period begins or the day DOM makes the final decision on the full application, which could either lengthen or shorten the HPE period. If a full Medicaid application is submitted to DOM following the HPE decision, the application is auto-assigned to the appropriate regional office but the application is completed by the central office staff member assigned to HPE. If the full application is approved, the application is forwarded to the regional office. The regional office is responsible for the case after approval, i.e., at the time of the first renewal or reported change. If the full application is denied, the denied application is forwarded to the assigned regional office and identifying information remains on file with the office in the event the individual reapplies.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual

CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |275 Effective Month: December 2016 101.06 IN-PERSON INTERVIEWS WITH DOM In-person interviews are required for all long term care (institutional) ABD programs with an asset test. The in-person interview requirement can be waived if the applicant is physically unable to appear for an in-person interview and there is no legal, self-designated or authorized representative for an ABD applicant. In such an instance, a telephone interview may be conducted. Although in-person interviews are not required for MAGI-related or ABD at-home applications, an applicant may request assistance with completing an application either in-person or by telephone. When assistance is requested, include all relevant information described in the “Interview Discussion, described below. Whenever an applicant requests an in-person interview, one will be conducted even if the program does not require an interview. At the interview the specialist reviews household composition and relationships to explain the individuals who are required to be included in the application and/or budgetary process, those who cannot be included. The specific programs and services available to the applicant and/or his family through Division of Medicaid are discussed and any questions the applicant has are addressed. In addition, referrals for services offered by other agencies are made, as appropriate. 101.06.01 INTERVIEW DISCUSSION Whenever an interview is conducted, the following specific areas must be addressed, if applicable: • The agency must allow an individual or individuals of the applicant’s choice to accompany and assist the applicant in the application or review process. • Eligibility requirements for the coverage group(s) the applicant appears potentially eligible in must be explained; • Coverage is limited to only one source of eligibility, i.e., SSI, ABD or MAGI- related. If the individual is eligible under another source, that source must terminate before ABD or MAGI-related eligibility begins.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual

CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |276 Effective Month: December 2016 INTERVIEW DISCUSSION (Continued) • The use and purpose of the application, including that the applicant is agreeing to all of the rights and responsibilities specified on the application by signing the form; • The applicable Standards of Promptness; • The requirement for Assignment of Third Party Rights; • The Quality Control review process; • The use of Social Security Numbers in computer matching programs; • Appeal Rights; • Child Support Cooperation Requirements; • Available services such as the EPSDT program and the annual physical for adults ; • Verification requirements and methods to be used to establish eligibility, including the use of electronic databases, collateral contacts, and documentary verification; • The change reporting requirements • Voter registration opportunities.

The following explanations are specific to ABD and must be addressed as applicable: • For institutional applicants, explain: o The Estate Recovery provision; o Spousal Impoverishment rules for IS/CS cases, including the community spouse resource and income limits, spousal allocation rules, allowable transfers of resources to the community spouse and the 90-day period allowed for transferring spousal resources; o Medicaid Income and protection of income for the month of entry, if applicable; o The Income Trust provision, if applicable; o Transfer of assets provision and the 5-year lookback period; o The 317 and PAS (Pre-Admission Screening) Forms must be submitted by the nursing facility and received by the RO prior to disposition of the application to document the medical necessity of the nursing home placement.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual

CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |277 Effective Month: December 2016 INTERVIEW DISCUSSION (Continued) • For at-home applicants, explain: o The income and resources of a spouse must be considered for the applicant’s eligibility, whether the spouse is applying or not; o The income of a stepparent cannot make a stepchild ineligible for ABD. • For both institutional and at-home coverage groups with an asset test, the authorization for financial institutions to disclose financial account information is a requirement for eligibility to be considered.

The following explanations are specific to MAGI-related applications and must be addressed if the MAGI applicant requests assistance in completing the application: • All possibilities for Medicaid eligibility must be tested before considering CHIP eligibility. Children who qualify for Medicaid cannot be approved for CHIP; • Requested verifications must be provided for each person included in the budgeting process if the verification cannot be obtained through available data sources. Failure to provide information may result in individual or multiple denials, depending on the program or type of verification which is lacking. • The income of an applicant’s spouse must be considered toward the applicant’s eligibility unless the spouse receives SSI. • The income of a stepparent living in the home with applicant children must be considered toward the children’s eligibility. • Verification of personal information, income and expenses is not needed for household members who are not included in the budgeting process.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual

CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |278 Effective Month: December 2016 101.06.02 CONCLUDING THE INTERVIEW At the conclusion of the interview, the applicant or his representative must have an understanding of the following: • Additional information the applicant must provide or actions he must take for eligibility to be determined; • Actions the agency must take to determine eligibility, • Notifications required, including a written notice of approval and the issuance of Medicaid or CHIP cards or a denial notice and/or the right to appeal any decision; • Redeterminations, i.e., annual eligibility reviews for children and annual or more frequent reviews, if necessary, for adults.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual

CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |300 Effective Month: December 2016 101.07 STANDARDS OF PROMPTNESS Eligibility must be determined within the appropriate timeframes for the program type as discussed below. If there is a delay in processing, the reason must be clearly documented in the record. 101.07.01 REGIONAL OFFICE RESPONSIBILITIES Each regional office must have controls in place which ensure timely application processing at all staff levels, including sufficient time for supervisory review and corrections. Applications should generally be processed in the order in which received, taking into consideration promptness and delay in receipt of verifications, and in some cases, urgent need. Under no circumstances should an application be approved without the proper verifications and documented eligibility for each applicant. 101.07.02 EXCEPTIONS TO TIMELY PROCESSING The agency must determine eligibility within established standards, except in unusual circumstances when a decision cannot be reached because of: • Failure or delay on the part of the applicant; • A disability decision has not been returned by DDS; or • Administrative or other emergency delay that could not be controlled by the agency. Time standards may not be used by the agency as a waiting period before determining eligibility or as a reason to deny eligibility because the agency has not determined eligibility within the time standards.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual

CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |301 Effective Month: December 2016 101.07.03 ABD STANDARDS OF PROMPTNESS Federal rules require that applications be approved or denied, and the applicant notified, within 45 days from the date the application was filed. The processing timeframe is 90 days when a disability determination is required before the eligibility determination can be completed. However, if a separate disability decision is not required, the 45-day standard applies. The applicable standard of promptness, i.e., 45 or 90 days, is applied to an ABD application from the date an application is filed to the date the notice of decision is mailed to the applicant. When there is a delay, the reason must be documented in the record. 101.07.04 MAGI-RELATED STANDARD OF PROMPTNESS MAGI-related programs have a 45-day standard of promptness. No more than 45 days may lapse from the date an application is filed to the date the notice of decision is mailed to the applicant. Any delays in processing MAGI-related applications must be client-caused or requested. When there is a delay, the reason must be documented in the record. NOTE: For MAGI applications filed with the FFM, the date of application is the date it is filed with the FFM; however, the standard of promptness begins when the application is received by DOM.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |325 Effective Month: December 2016 101.08 PROCESSING APPLICATIONS Specialists must determine eligibility based on information contained on the application form as well as information secured during the application process. Appropriate DOM forms, along with other legal or official documents which support the eligibility decision must be filed in the case record. As part of the eligibility process, information provided by the applicant, secured through electronic data bases and obtained from other sources must be verified, documented, and evaluated by the specialist prior to making the eligibility decision. If information provided by or on behalf of an applicant on the application form is consistent with information obtained through electronic data sources, eligibility must be determined based on such information. An applicant must not be required to provide additional verification or documentation unless needed information cannot be obtained electronically or the information obtained electronically is not consistent with information declared on the application or otherwise secured during the application process. 101.08.01 MAKING AN ELIGIBILITY DECISION Eligibility decisions are made using the following: • Verification - Verification is the substantiation, confirmation or authentication of an assertion, a claim or previously submitted information. Verification is obtained through the use of electronic data sources or by information provided by the applicant. The specialist will accept reasonable documentary verification provided by the applicant and will be primarily concerned with how adequately the verification proves the statements on the application form. Only information material to the applicant’s eligibility is subject to verification, through electronic means or otherwise. Verification provided by an applicant or beneficiary must never be discarded, destroyed, ignored or altered.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |326 Effective Month: December 2016 MAKING AN ELIGIBILITY DECISION (Continued) • Documentation - All cases must be thoroughly documented. Documentation is the written record of all information pertaining to the eligibility decision. Case documentation includes the completed application form, the specialist’s verbal and written contacts with the applicant, information requested and received from electronic data sources, the applicant or third party sources, such as governmental or nongovernmental agencies, businesses and individuals, and notification of the eligibility decision. When an applicant claims no income or resources, the specialist must fully document the facts provided to substantiate these claims. “Applicant states none” is not sufficient documentation. The record must also show why the statement of the applicant or beneficiary is reasonable and acceptable. NOTE: For MAGI applicants who attest on the application form that one or more household members receive income that does not count (such as SSI, TANF, VA benefits, Workers’ Compensation, Child Support), consider this as documentation of income available to support the family. In other words, the household is not a $0 income household but rather a household sustained by income that does not count. If the application form has no mention of receipt of non-countable income and there is no declared income or resources, the record must contain a reasonable explanation of how the household is meeting basic needs. When action is taken to deny the application because the applicant has not provided the information necessary to determine eligibility within the specified timeframe, documentation in the record must show an appropriate request(s) was issued to the applicant. • Evaluation –Information provided by the applicant or obtained through electronic data sources or third party sources must be assessed prior to making an eligibility decision. When information is not logical, consistent or reasonable, it must be resolved prior to determining eligibility.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |327 Effective Month: December 2016 MAKING AN ELIGIBILITY DECISION (Continued) When there is conflicting information, the reliability of each source of information must be evaluated and the case record should specify which source was accepted and why. The final determination of eligibility is made based on the most reliable source available. 101.08.02 USE OF COLLATERAL CONTACTS If needed verification is not available from an electronic data source, the applicant is generally the source used to supply needed verification. However, at times information may also be obtained directly from third parties.

The specialist has permission to obtain needed verifications based on the signed and dated application form. When it is necessary to request information from banks, insurance companies, or other sources that do not disclose information without a signed release, the DOM-301, Authorization to Release Information, should be used or a copy of signature page of the ABD application form that contains the Release of Information authorization by the applicant. Public records or records available from other agencies may be consulted without the consent of the individual.

Applicants should not be asked to verify information from sources which the agency has access to. This includes electronic data sources and other federal or state benefit information that is available to the agency.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |328 Effective Month: December 2016 101.08.03 REQUESTING INFORMATION FROM THE APPLICANT The applicant has the primary responsibility for providing documentary evidence to verify statements made on the application or to resolve any questionable information when verification from electronic data sources is not available or is inconsistent with applicant provided statements. When additional information is needed, the following action is taken: ABD Applicants MAGI-Related Applicants

Issue DOM-307, Request for Information, to take a necessary action (such as appear for an in-person interview or apply for a specific benefit, etc.) or to request specific information that must be provided based on the ABD application responses. Request only needed verification and required actions; do not request information that does not apply.

Direct contact must be attempted before issuing a written request for information when information from electronic data sources conflicts with information provided on the MAGI application. If a reasonable explanation is provided, document the contact for the record. If direct contact is unsuccessful, document each attempted contact and issue written notice as described below.

Issue DOM-309, Second Request for Information, at the end of the DOM-307 request period for any missing information or action addressed on the DOM-307. Do not request any new or additional information on the 309; a new 307/309 is required for information or action not addressed in a previous 307/309.

Issue DOM-307, Request for Information, when needed information is not available from electronic data sources or attempts to contact the applicant by telephone are unsuccessful. List specific information needed to determine eligibility.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |329 Effective Month: December 2016

Request for additional time – for both ABD and MAGI, if the applicant contacts the agency to request additional time, the applicant will have the remainder of the 45-day processing period to submit requested information or take necessary action. (NOTE: for ABD disability applications subject to the 90-day processing period, a denial cannot be issued prior to securing the DDS decision, which may allow additional time for the ABD applicant to provide other needed information.) Explain to the applicant the latest date that can be allowed to submit information or take necessary action in order to avoid a denial for failure to provide requested information. Assist the applicant as needed or requested to secure needed information.

Failure to provide requested information – it the applicant has not fully complied by the due date on the 307 (for MAGI) or on the 309 (for ABD) and has not requested additional time, the application will be denied due to the failure to provide needed information or take required action. Document the denial notice to inform the applicant of the missing verification or action that is the basis for the denial.

101.08.03A ELECTRONIC DATA SOURCES UTILIZED BY DOM For MAGI-related applications, all available electronic data sources are utilized and evaluated to attempt an eligibility determination. If information provided on the application is not consistent with electronic data source verification, the head of the household for the MAGI application must be contacted by telephone for a reasonable explanation of any relevant discrepant information. If a reasonable explanation is not provided, paper verification is requested using the DOM-307, Request for Information, as outlined above.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |330 Effective Month: December 2016 ELECTRONIC DATA SOURCES UTILIZED BY DOM (Continued) ABD applications utilize the same electronic data sources shown below.

Electronic data sources utilized by the agency include the following:

• Social Security Administration – verifies non-financial factors of eligibility such as SSN verification, U.S. citizenship verification, age verification, disability onset date, if appropriate, and financial verification of benefits paid through SSA. • Department of Homeland Security – verifies immigration status of immigrants in possession of immigration or naturalization papers that can be used to match with Homeland Security. • Department of Employment Security – verifies wages reported to the agency as the State Wage Information Collection or SWICA agency. Also verifies Unemployment Compensation benefits paid. • TALX (or the Work Number) – commercial database that verifies wages reported by employers that utilize this service. • EVVE or Electronic Verification of Vital Events – verifies birth records for births in all states that utilize this service. • Office of Child Support Enforcement (through the Department of Human Services) – verifies compliance with child support requirements for adults subject to this provision as a post-eligibility requirement. • PERS or Public Employees Retirement System (in MS) – verifies benefits paid by PERS.

101.08.03B ELECTRONIC DATA SOURCES UTILIZED BY THE FFM The FFM utilizes electronic data sources such as the Social Security Administration, TALX, and the Department of Homeland Security to determine eligibility for participation in a qualified health plan or potential eligibility for MAGI-related Medicaid or CHIP. Verified information is passed to DOM through the Account Transfer (AT) record along with attested information from the application filed with the FFM. AT records are then matched or are available for matching with DOM utilized data sources.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |331 Effective Month: December 2016 101.08.04 SUPERVISORY REVIEW Each ABD and MAGI-related eligibility determination must be authorized by a supervisor, who is responsible for the accuracy, completeness and consistency of information contained in the case record. The supervisor is attesting to the validity of the action taken on the case when it is authorized in the system. The exceptions to supervisory review include: childless adult denials, the addition of a deemed infant to a case, family planning and pregnant women approvals. 101.08.05 APPLICATION ACTIONS All applications will be subject to one of the following actions: • Approval – When all of the eligibility factors are met, the application is approved and the applicant is notified in writing of the approval. • Denial – When one or more eligibility factors are not met, the application is denied and the applicant is notified in writing of the denial. Adverse action does not apply. NOTE: Death is not an appropriate reason to deny a Medicaid application. If the applicant dies before a final eligibility determination is made, the application process must be continued to completion. • Withdrawal – When the applicant decides to withdraw his request for assistance during the application process, it is not necessary to complete any remaining verification and evaluation. If the applicant is present, the specialist will obtain the request for withdrawal in writing. When the request to withdraw is not made in person, the specialist will document the case to reflect the specifics of the request. The application will be denied and appropriate notice issued.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |332 Effective Month: December 2016 101.08.06 COMPLIANCE AFTER DENIAL If a MAGI or ABD applicant provides all needed information to complete the application before the end of the month following the month of the denial, use the denied application form to establish eligibility using the original application date. Reinstate the application in the system using the original application date.

For example, the application is denied on September 12th. If all needed information is provided on or before October 31st, the application can be reinstated.

If, as a result of new information provided, additional information is needed to complete the application, attempt to handle these issues by telephone contact, if possible. If not possible, issue a DOM-307 (and DOM-309 for ABD, if needed) specifying what is needed to comply. Allow 12 days for the information to be returned.

• If requested information is not provided, no further contact with the individual is required unless the information needed is provided during the remainder of the compliance period. Close the reinstatement contact, delete the time period and document the case narrative.

• If all information is provided, take action to approve the application if eligible or deny the application for the appropriate reason if ineligible.

NOTE: if the ABD application was denied because the applicant did not appear for a required interview and did not request an alternate arrangement to be interviewed, a reapplication is required.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |350 Effective Month: December 2016 101.09 COMBINATION MAGI AND ABD APPLICATIONS Although MAGI and ABD are separate programs, there are common elements that allow an individual to apply in one program but be determined eligible in the other using available information.

The MAGI application asks specific questions at the individual level regarding possible ABD eligibility. These questions ask if the applying household member:

• is disabled, or • has a physical, mental or emotional condition that limits common activities, or • lives in a medical facility or nursing home.

An affirmative response to any of these questions requires further development as quickly as possible during the MAGI application process to follow up on possible ABD eligibility if it is unlikely that the individual will qualify for MAGI based on application information. For example, an applying household member is over the age of 18 and is not a parent or caretaker of a minor child in the home, or the parent/caretaker has income over the limit for adult coverage, or a disabled child’s family income is over the Medicaid and CHIP limit. In all of these situations, if a disability is alleged for an applying MAGI household member, that individual must be allowed the opportunity to apply for ABD in an expeditious manner.

MAGI Application Filed with DOM Indicates Possible ABD Eligibility

To fulfill the requirement for a MAGI applicant to apply for ABD when a MAGI application indicates possible ABD eligibility, do the following:

• Issue the ABD application form (DOM-300) via DOM-307 requesting only the information that is not available as part of the MAGI application process. The types of verification needed to establish ABD eligibility may be:

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |351 Effective Month: December 2016 COMBINATION MAGI AND ABD APPLICATIONS (Continued)

o Requesting disability information for a DDS decision if disability cannot be established using electronic verification from SSA on the SVES. o Verification of any income not counted for MAGI purposes, such as VA benefits, that will not be verified during the MAGI application process. o Verification of resources for the individual, couple, or parent(s) of a disabled child, which are not considered for MAGI eligibility.

• A signed ABD application form is required to formalize receipt of an ABD application. If a signed (complete or incomplete) ABD application form is not received, document the MAGI case that there is no further action required regarding ABD follow-up.

• If a signed ABD application form is received but missing required information, obtain the information by using telephone contact when possible or the issuance of DOM-307/309 to obtain missing information.

• Although an in-person interview may ordinarily be required for ABD, a telephone interview with the ABD applicant or representative may be used in this situation to describe the ABD application process and to inform the ABD applicant of any other requirements unique to ABD. These include ownership of resources, requirements to consent to the AVS (Asset Verification System) requirement described on the application form, any applicable long term care provisions such as estate recovery, spousal impoverishment, transfer of assets, Medicaid Income and the Income Trust provision that are not applicable to MAGI eligibility.

If the ABD applicant(s) follow through with the remaining ABD application requirements, such as providing requested information or taking required actions, the ABD application can be processed and approved regardless of the action taken on the MAGI application. If the MAGI and ABD applications are approved, the case becomes a combination ABD/MAGI case in MEDS and is handled accordingly.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |352 Effective Month: December 2016 COMBINATION MAGI AND ABD APPLICATIONS (Continued)

MAGI Application Filed with the FFM Indicates Possible ABD Eligibility

For MAGI applications filed with the FFM and referred to DOM as an Account Transfer, the system recognizes any affirmative responses to the questions that indicate a request to apply for ABD Medicaid and issues DOM-304, Non-MAGI Application Letter (located in the Appendix page by the same name). This letter informs the applying household member that additional information will be needed if the applying household member wants to pursue applying for Medicaid on the basis of disability, i.e., resource information and disability information unless the individual has already been determined disabled by SSA. The letter instructs the individual to sign, date and return the letter to DOM by mail, in person, by fax or email if he/she wants to continue with an application for ABD Medicaid or, if needed, the individual can contact the agency by phone to continue the process.

If an individual signs and returns the “Non-MAGI letter” to the agency via any means acceptable for filing an application, an ABD application must be issued to the individual and the steps described above in “MAGI Application Filed with DOM Indicates Possible ABD Eligibility” must be followed for processing the ABD application.

If a signed non-MAGI letter is not returned to the agency, no further action is required.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |375 Effective Month: December 2016 101.10 ELIGIBILITY DATES The following discussion addresses Medicaid and CHIP beginning dates of eligibility, ending dates of eligibility, and retroactive Medicaid eligibility.

101.10.01 BEGINNING DATES OF MEDICAID ELIGIBILITY Medicaid applicants, including an applicant who dies prior to filing an application or dies prior to completion of the application process, may qualify for Medicaid on one of the following dates:

• The first day of the month of the application, provided all eligibility factors are met for the first day of the month;

• The first day of the month after the month of application in which all eligibility factors are met;

• The first day of the first, second or third month prior to the month of application when conditions are met for retroactive Medicaid.

• The first day of the month following the month of approval for QMB-only (Qualified Medicare Beneficiary) eligibility. There is no retroactive Medicaid possible for a QMB-only.

• The Hospital Presumptive Eligibility (HPE) beginning date of eligibility is the date the HPE application is approved by authorized hospital staff. 01.10.02 BEGINNING DATES OF CHIP ELIGIBILITY

The benefit start date for CHIP is the first day of the month following the month of application, provided all eligibility factors are met. There is no retroactive eligibility for CHIP-eligible children, other than the newborn exception described below.

Newborn exception: The start date for a CHIP-eligible newborn may be retroactive to the date of birth if the application is filed within 31 days of birth. The 31-day count for the application to be filed begins the day following the infant’s date of birth.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |376 Effective Month: December 2016 101.10.03 TERMINATION DATES Eligibility for a Medicaid or CHIP recipient will end on one of the following days of the month, unless otherwise noted:

• The last day of the month in which the client was eligible; or • The death date of the recipient. or • The date the recipient entered a public institution. • Hospital Presumptive Eligibility (HPE) termination dates are either the last day of the month of the HPE period or the day of the month that the full application for Medicaid is denied.

101.10.04 RETROACTIVE MEDICAID ELIGIBILITY Retroactive Medicaid eligibility may be available to any Medicaid applicant who received medical care prior to applying for Medicaid. Applicants may qualify for coverage for a 3-month period prior to the month of the application. Retroactive eligibility can cover all 3 months of the prior period or any month(s) in the 3-month period. In addition: • Each applicant must be informed of the availability of retroactive Medicaid coverage. • The applicant’s statement is accepted regarding medical expenses incurred in the retroactive period. • Retroactive Medicaid may also be available to an individual who is added to a case (e.g., child returns home). • The applicant does not have to be eligible in the month of application (or current month) to be eligible for one or more months of retroactive Medicaid. NOTE: Children have continuous eligibility. A child who is eligible only in a retroactive month will receive Medicaid for 12-continuous months beginning with the month eligibility starts. • The applicant or recipient may ask for retroactive Medicaid coverage at any time.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |377 Effective Month: December 2016 RETROACTIVE MEDICAID ELIGIBILITY (Continued) • The date of application, rather than the date of the eligibility determination, establishes the beginning of the three-month retroactive period. • There is no provision for retroactive coverage in the Qualified Medicare Beneficiary (QMB) program. QMB eligibility begins the month following the month of authorization. It is not appropriate to place a QMB-only approval into an SLMB or QI-1 category of eligibility to provide retroactive payment of Part B premiums for the retro period. • Hospital Presumptive Eligibility (HPE) has no retroactive coverage. If a full application for Medicaid is filed and approved, retroactive coverage is available for up to 3 months prior to the month the full Medicaid application is filed. In addition, any partial month of eligibility granted under HPE begin date rules will be changed to full month eligibility.

101.10.04A RETROACTIVE MEDICAID FOR ABD APPLICATIONS Eligibility in a retroactive month cannot be assumed based on current month eligibility. Determine eligibility for each month separately using the eligibility rules in effect for that month, actual income received in each month and actual resources available in each month. NOTE: Annual Cost-of-Living Adjustment (COLA) increases in Federal benefits cannot be used to determine ABD eligibility in any given year until the Federal Poverty Level (FPL) limits have been implemented for that year. Therefore, when determining retroactive or ongoing eligibility for the months of January, February and possibly March, the prior benefit amount must be budgeted, rather than the actual amount.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |378 Effective Month: December 2016 101.10.04B RETROACTIVE MEDICAID FOR MAGI-RELATED APPLICATIONS Income determined for current eligibility is used for the retroactive period for MAGI-related cases unless there was a change that must be considered for eligibility in the retroactive period. Accept the applicant’s statement regarding income sources and amounts in the retroactive period unless there is some reason to question the accuracy of the statement, such as electronic data source verification is inconsistent with the applicant’s statements or declared information For purposes of determining Extended Medicaid eligibility, retroactive Medicaid can be used to determine whether an applicant would have been eligible for Medical Assistance (in three of the last six months. 101.10.05 RETROACTIVE MEDICAID FOR DECEASED APPLICANTS An application for retroactive Medicaid coverage may be made on behalf of a deceased person. Retroactive eligibility can cover all 3 months prior to the month of application or any month(s) in the 3-month period if the deceased person is found to be eligible. 101.10.06 RETROACTIVE MEDICAID FOR SSI ELIGIBLES AND FILLING IN GAPS Persons eligible for SSI may be eligible for additional months of eligibility beyond the SSI retroactive period. This period of coverage includes the month of application for SSI and any other missing months of eligibility that exist until the month the SSI payment begins. The SSI eligible person must apply for and be determined eligible for ABD coverage for the interim period of missing SSI eligibility.

An application for the interim period of missing SSI eligibility can be filed at any time and may or may not be filed in conjunction with an application for SSI retroactive Medicaid. However, if an application for retroactive Medicaid was filed and either approved or denied within 90-days of a request to fill in missing month(s) of SSI eligibility, reinstate the prior application using current verification needed to determine eligibility for any missing month(s). The reinstatement is only for the purpose of using the previous application. Eligibility is approved only for the missing month(s) provided the SSI individual is eligible in the missing month(s).

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual

CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |400 Effective Month: December 2016 101.11 NOTIFICATION The recipient and, when applicable, the medical facility must be notified in writing of the action taken on an application or an active case when eligibility or benefit level is affected by a change either at the time of a full review or as a result of a reported change prompting a special review. Notices are generated by the system based on the type of contact and the results of the eligibility determination. NOTE: It is the specialist’s responsibility to review and, if needed, correct notices in the system before they are mailed to the recipient. If a manual notice is required for the recipient, refer to instructions for the DOM-305, Notice of Action, or DOM-306, Notice of Adverse Action. When a manual notice must be issued to a facility, DOM-317, Exchange of Information Between Long Term Care Facility and Medicaid Regional Office, is used. 101.11.01 ADVANCE NOTICE Federal regulations require issuance of a notice of adverse action 10 days before the effective date of an action to reduce or terminate benefits. However, federal regulations also require that for continuation of benefits to apply when requesting a hearing, the 10-day advance notice period includes 5-days mailing time. To simplify this requirement, the adverse action deadline is set for the 15th of each month except in February, which is the 13th of the month, to ensure a minimum of 5-days mailing time. During the advance notice period, the recipient is allowed time to fully comply with unmet requirements, provide information or verification that will alter the decision to terminate or reduce benefits, or request a Fair Hearing with continued benefits. If this occurs, the agency must take prompt and appropriate action to reinstate benefits.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual

CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |401 Effective Month: December 2016 101.11.02 EXCEPTIONS TO ADVANCE NOTICE Unless noted, the following actions require notification to the recipient; however, 15-day advance notice is not required. Death When the agency has factual information verifying the death of a recipient, the date of death and verification source must be recorded in the record. A notice is not generated by the system if the termination reason is death. Some acceptable sources to verify the death date are: • SVES or SDX; • Report from recipient’s representative or the MAGI Head of Household; • Viewing the death certificate, • Contact with the funeral home or the attending physician; • DOM-317 from the nursing home or contact with the hospital or nursing home where the patient died; • Dated newspaper clippings. Loss of State Residence When the agency establishes that a recipient has moved from the state through information received from the recipient or because another state reports the client has been accepted as a resident for Medicaid in that state, advance notice of closure is not required. Resident of a Public Institution When the agency has established that the recipient has been admitted to a public institution, such as a prison or a state hospital in a non-Title XIX facility, advance notice of termination is not required.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual

CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |402 Effective Month: December 2016 EXCEPTIONS TO ADVANCE NOTICE (Continued) Unable to Locate When a recipient’s whereabouts are unknown, the agency must take reasonable efforts to locate the recipient. When agency mail is returned by the post office with no forwarding address and other efforts to locate the recipient are unsuccessful, eligibility will be terminated. However, if the client’s whereabouts subsequently become known during the time the client is eligible for services, the case must be reinstated. Voluntary Request for Closure If the recipient or his designated representative voluntarily requests closure, advance notice is not required. If the request is made in person, the specialist will obtain the request in writing. Otherwise, the specialist will document the case to reflect the specifics of the request. Eligible for Medicaid through Another Source If a MAGI-related or ABD recipient becomes Medicaid-eligible through SSI or foster care, advance notice of termination of benefits authorized through the Medicaid Regional Office is not required.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |425 Effective Month: December 2016 101.12 PROCESSING DOM EMPLOYEES/FAMILY MEMBERS CASES Cases for DOM employees, members of their households and immediate family members require special processing and maintenance as follows. • DOM employees must not process their own application, redetermination, or change. They must not directly view, add, remove, replace or edit system information or documents and verifications in the case record. • Further, DOM employees must not process or maintain case(s) that include a member of their household or immediate family. They must not process the application, redetermination or change on these individuals’ cases. They must not directly view, add, remove, replace or edit system information or documents and verifications in the case record. • Immediate family includes the employee’s spouse, children, children’s spouses and the following relations to the employee or employee’s spouse: mother, father, step- parent, brother, sister, niece, nephew, grandparent, grandchildren. • Individuals living in the home with the employee are included as immediate family members even if they are not one of the relationships listed above. • DOM employees, household members and their immediate family members must be marked as DOM employees in the system to limit system access to all members of the case. The case records must be maintained in a locked file by the person responsible for the case. • Cases involving family and friends can potentially represent an impropriety or conflict of interest to an employee; therefore, it is the employee’s responsibility to inform the supervisor if the application or case of a family member or friend has been assigned to them. • DOM employees must never directly or indirectly influence or request that another DOM employee process an application for themselves, family members, household members or friends outside of normal assignment and authorization processes. • Individuals who fail to follow the guidelines for processing applications for employees and their family members are subject to disciplinary action.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |426 Effective Month: December 2016 Procedures for Processing Applications of DOM employees, Members of Their Household or Immediate Family Members Any application or active case involving a DOM employee, household member or immediate family member, as defined above, in any regional office must be processed using the following guidelines: The Applicant is The Person to Process the Application is The Person to Review & Authorize the Action is DOM Employee Bureau Director, Deputy (BDD) Bureau Director (BD) Employee’s Spouse or Minor or Adult Child Bureau Director, Deputy Bureau Director Other Immediate Family or Household Member Division Director Assigned by BDD Bureau Director, Deputy BDD, BDD’s Spouse or Minor or Adult Child Bureau Director Bureau Director Other Immediate Family Member or Household Member of BDD Assistant Supervisor Bureau Director

BD, BD’s Spouse or Minor or Adult Child If case is located in service area directly under the BD’s supervision, the person to process the application and reviews is the Central Office manager. If not, the BDD for the office is the responsible. Central Office Manager Other Immediate Family Member or Household Member of BD If case is located in service area directly under the BD’s supervision, the person to process the application and reviews is the Central Office manager. If not, the BDD for the office is the responsible. Central Office Manager

Prior to authorizing eligibility, the regional Bureau Director, Deputy, Bureau Director, or State Office Manager, as appropriate, will thoroughly review the case and determine the accuracy of the eligibility decision. This may include additional contact with the applicant or others when deemed necessary to make a determination of eligibility. The process described above includes all activity on affected cases at the time of application and review, including special reviews of all such cases.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |450 Effective Month: December 2016 101.13 SERVICE DELIVERY SYSTEMS The Division of Medicaid operates under two different payment models for services which are fee for service and coordinated care. Once an applicant is approved for Medicaid or CHIP, the individual is enrolled in one of these payment models based on their category of eligibility, age and whether enrollment is mandatory or optional for their category. 1. Fee for Service (FFS) – the recipient chooses his/her own provider of service that accepts Medicaid and the provider is reimbursed by DOM. Fee for Service recipients are entitled to the full array of Mississippi Medicaid State Plan covered services. 2. Coordinated Care – this is a type of managed care whereby certain recipients are either required to enroll or may voluntarily enroll in a Coordinated Care Organization (CCO) and have their medical care managed by the CCO selected. CCO’s connect enrollees to a medical home and provide care management and disease management programs in an effort to provide cost-effective medical services. CCO’s are paid a capitation rate per enrollee and in turn, the CCO pays the medical claims to the Medicaid provider. CCO’s are required to cover all Mississippi Medicaid State Plan covered services unless the contract with the CCO’s states otherwise; however, CCO’s can also offer additional services not covered in the Mississippi State Plan, such as additional physician visits or additional pharmacy benefits. CHIP enrollees are required to select a CCO. Benefits covered are those required by the DOM CHIP Plan. For additional information on MSCAN and the mandatory and optional categories of eligibility that can or must enroll in a CCO, refer to the DOM website.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |475 Effective Month: December 2016 101.14 CONTINUOUS ELIGIBILITY FOR CHILDREN When a child under age 19 is approved for Medicaid or CHIP, eligibility continues for 12 months, regardless of changes in family income and other household circumstances. This policy must be applied when determining and re- determining eligibility for a child under age 19, regardless of category (MAGI- related or ABD).

Continuous coverage may also be referred to as a protected period because the child cannot lose eligibility in the assigned category, unless one of a limited number of early termination reasons is met. In addition, the child’s program cannot be changed (Medicaid to CHIP or vice versa), unless the Head of Household voluntarily requests early termination or the child was approved in error in the current program.

101.14.01 EARLY TERMINATION REASONS FOR CHILDREN

The following reasons may shorten the 12-month certification for a child in MAGI-related or ABD programs, as applicable.

• If a child dies, his eligibility must be terminated.

• If a child moves out of the state, his eligibility must be terminated.

• If a child attains the maximum age for his program and an assessment of continued eligibility indicates the child is not eligible in any other MAGI- related or ABD program, his eligibility must be terminated. Refer to “Exparte Reviews” later in this chapter for further discussion on assessing eligibility in another program.

o When a child in the Disabled Child Living At-Home program will age out of this program, continued eligibility must be assessed in another program.

o When a MAGI-related child turning age 19 is pregnant, the child will be placed in the COE-088 program through her post-partum period if the pregnancy information is verified and coded in the system.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |476 Effective Month: December 2016

EARLY TERMINATION REASONS FOR CHILDREN (Continued)

o At review, an assessment of eligibility in other age-related MAGI categories is automated in the system. For example, an uninsured child turning age 6 in COE-072 during the new 12-month eligibility period will move to either COE-073, 074 or CHIP the month following his/her 6th birthday.

• When the basis of a child’s eligibility is long term care, eligibility must be terminated if the child is discharged from the facility.

• If a child becomes an inmate in a public institution, his eligibility must be terminated. • If a child becomes eligible for Medicaid through SSI or Foster Care, coverage authorized through the Medicaid Regional Office will be terminated because the child must have only one source of eligibility. (NOTE: If the child becomes eligible in another program authorized by the RO, termination in the current program must be coordinated with the opening in the new program.) • If a child is approved in error, his eligibility must be terminated.

• If a child cannot be located after reasonable efforts, his eligibility must be terminated.

• If there is a voluntary request for closure, eligibility must be terminated.

In addition to the above termination reasons, CHIP eligibility will also be terminated within the 12-month period for these additional reasons:

• The CHIP-eligible child becomes covered by other full health insurance;

• The CHIP-eligible child becomes eligible in the 88 program due to pregnancy. NOTE: If the pregnant minor’s post-partum period in COE-088 ends prior to the end of her assigned 12 months of continuous eligibility, she will be automatically transferred back to CHIP the month following the end of her post-partum period.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |477 Effective Month: December 2016 EARLY TERMINATION REASONS FOR CHILDREN (Continued)

Other changes for children under age 19 in a child or family-related category of eligibility do not affect the child’s eligibility prior to the end of the 12 months of continuous eligibility. 101.14.02 DEEMED ELIGIBLE INFANTS A deemed eligible infant is a child whose mother was eligible for Medicaid in the child’s birth month; however, there is no requirement that the child remain with the mother. The deemed eligible child has continuous Medicaid eligibility for a 13-month period from his birth month through the month of the first birthday unless one of the above early termination reasons is applicable.

Specialists have to ensure deemed eligible children are not:

• Terminated prior to completion of the 13th month of Medicaid eligibility; or

• Changed from Medicaid to CHIP prior to completion of the 13th month of eligibility, unless the parent or other responsible person voluntarily requests early Medicaid termination.

The deemed child’s eligibility start date should always be his birth month, regardless of the date the agency authorizes eligibility for the child. To terminate eligibility at the end of the deemed period or to make a timely program change from Medicaid to CHIP, the child’s time span begin date should be set for the month following the month of the first birthday.

If the mother is not eligible for Medicaid at the time her child is born, she may apply for Medicaid for herself and her newborn. The application must be filed timely in order for Medicaid to be retroactive to the birth of the child, i.e., an application must be filed by the end of the 3rd month following the birth month of the child. If all eligibility factors are met, the mother and newborn may be eligible for up to 3 months prior to the month the Medicaid application is filed. If the mother and newborn are determined eligible, the mother will be covered throughout her post-partum period and the newborn will be eligible for 12 continuous months.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |478 Effective Month: December 2016 101.14.03 ADULTS Adults generally have no protected period of eligibility. Changes in income and other circumstances can impact an adult’s eligibility as such changes occur. However, women eligible solely due to pregnancy in the COE-088 program are provided coverage from their first eligible month through the post-partum months regardless of any subsequent changes in income, household composition, etc. This includes women whose eligibility originated in a non- pregnancy related coverage group, such as QMB or Family Planning, who are determined eligible for COE-088 and transition to COE-088 for coverage of pregnancy related services for the duration of her pregnancy and post-partum months. In such instances, eligibility must be reviewed for the impact of any changes in circumstances after transitioning back to her original coverage group.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |500 Effective Month: December 2016 101.15 THE REDETERMINATION OR RENEWAL PROCESS Redetermination is the process of verifying whether a recipient continues to meet the eligibility requirements of a particular program. Redeterminations are classified as either regular or special reviews. A regular review is an annual review of all eligibility factors that are subject to change. A special review is completed when a portion of the case must be re- worked or case information must be updated because of a change. This chapter addresses the redetermination process.

101.15.01 REGULAR REDETERMINATIONS OR RENEWALS – MAGI & ABD Federal regulations require that the eligibility of every Medicaid and CHIP recipient be reviewed at least every 12 months. Mississippi state law also requires annual reviews. During the regular redetermination process, the recipient’s circumstances are reviewed and each eligibility factor that is subject to change, such as income and/or resources, is re-evaluated. Recipients are not asked to provide information that is not relevant to ongoing eligibility or that already been provided and is not subject to change.

101.15.01A FREQUENCY OF REVIEWS A full review must be conducted for all eligible household members (MAGI and ABD) at the earliest 12-month review when case members have different review due dates. When a redetermination is currently due for some but not all case members, a redetermination contact will be set on everyone to attempt to align redetermination dates for the following year and assure one annual review for case members:

• Adults in the case can have their 12-month review period shortened by a change in circumstances that affects adult(s) in the case. The exception is a pregnant adult who is eligible in COE-088.

• Children that are not due for review require special handling to ensure protection of their 12-months of continuous eligibility, as described in 101.16.01B and 101.16.01C below.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |501 Effective Month: December 2016 101.15.01B PROCESSING CHILDREN CURRENTLY DUE FOR REVIEW If a child, currently due for review, is determined ineligible or will have a program change from Medicaid to CHIP or vice versa, the action must be effective at the end of the current 12 month review period. To process the termination or change in the system, the specialist will enter the month following the child’s review due month as the time span begin date.

Example: The child’s review due date is May. The time span begin date is set for June. If timely action is taken by the adverse action deadline in May, a termination will be effective May 31st. If a program change is involved, action must be taken prior to the end of May. 101.15.01C PROCESSING CHILDREN NOT CURRENTLY DUE FOR REVIEW Each child must be provided 12 months of continuous eligibility in his eligible category. Prior to the end of the 12-month period, a child cannot be: • Terminated, unless an early termination reason exists, or • Changed from one program to another (Medicaid to CHIP or vice versa) unless the parent or other authorized person voluntarily requests early closure in the current program or the original determination was in error.

When reviewing a case with different review due dates and the current review is for the person with the earliest review due date, it is appropriate to set a redetermination contact for all case members; however, the current review and any requests for information must be focused on the case member(s) due for review. Do not request any information on any children with a future review due date. If updated information is provided during the review which results in eligibility for all case members, eligibility can be extended for all members, including children with a future review due date.

If updated information results in ineligibility for any child with a review due date in the future, it is not possible to take action to terminate eligibility prior to the end of the 12-month continuous period. Future termination dates for children not currently due for review are not permitted. Instead, the child or children must be fully reviewed at the end of the 12-month protected period of eligibility. This includes a deemed eligible newborn who is eligible for the first full year of life. Retract eligibility and cancel the redetermination contact for any children affected by a finding of ineligibility.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |502 Effective Month: December 2016 PROCESSING CHILDREN NOT CURRENTLY DUE FOR REVIEW (Continued) When a program change is involved for a child with a future review date, the change cannot be made until the end of the child’s current eligibility period unless the parent or other authorized person voluntarily requests early termination in the current program. The request must be made in writing by the parent or other authorized person and filed in the case record. Retract eligibility and cancel the redetermination contact for any children affected by a program change that has not been approved in writing 101.15.01D PROCESSING AN APPLICATION AND A REVIEW As previously indicated, when an application is filed to add a new child or adult (MAGI or ABD) to an active case, a review is completed for existing case members at the same time the application for the new member is processed. However, the same policy requirements apply for an application and a review as exists for processing an active case with children not currently due for review:

• Do not request any information on any children with a future review due date. • If updated information is provided for the applicant that results in eligibility for all case members, eligibility can be extended for existing case members, including children with a future review due date. • If updated eligibility results in ineligibility for any child with a future review due date, the child or children must be fully reviewed at the end of their 12-month protected period. • A program change for a child with a future review date is prohibited unless the parent or other authorized person requests early termination in the current program. • If a finding of ineligibility or a program change results for existing children in the case who are not due for review, retract eligibility and cancel the redetermination contact for the child(ren) with a future review due date.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |503 Effective Month: December 2016 101.15.02 ASSIGNMENT OF REVIEW DUE DATES A regular review must be completed on each recipient at intervals not to exceed 12 months. The system automatically sets a 12-month review at application and redetermination as follows:

APPLICATIONS REVIEWS MAGI applications – a Medicaid application month starts the 12-month count. (Application month + 11 months = review due date.)

For CHIP, the benefit month starts the 12-month count (Month after month of application + 11 months = review due date.) MAGI and ABD review due dates are determined using the time period begin month to start the 12-month count. (Begin month of time period + 11 months = review due date.) ABD applications – the month the supervisor authorizes eligibility starts the 12-month count. (Supervisor authorization month + 11 = review due date.)

The reviewing supervisor is responsible for ensuring the proper review due date is assigned to each individual and for correcting or adjusting system-assigned dates at authorization when needed. No individual’s review due may be adjusted to exceed 12 months.

Setting Correct Time Spans to Ensure a Child’s 12-Months Continuous Eligibility

Because children (MAGI or ABD) can be added to a case at different times (birth of a child or addition of a child to a case), not everyone within a case may have the same review due date. As stated previously, all children under age 19 (MAGI and ABD) are entitled to 12-months of continuous eligibility.

The system sets the review due date based on the beginning month of the time period entered. When completing MAGI and/or ABD redeterminations, the time period must be set as follows:

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |504 Effective Month: December 2016 ASSIGNMENT OF REVIEW DUE DATES (Continued) Overdue for Review Set the time span for the month following the month the pre- populated renewal form is received. Children who are approved will have a new review due date 12 months from the time period begin date.

Ineligible children must have a full review at the end of their 12- month protected period.

Current Reviews Set the time span for the month following the earliest redetermination due date for the case. This is the starting point to begin the eligibility assessment. If all children are approved again in the same program, the new review dates will be 12 months from the time period begin month.

Early Reviews Begin the time span with the month following the earliest redetermination due month for the case. This is the starting point to begin the eligibility assessment. If all children are approved again in the same program, the new review dates will be 12 months from the time period begin month.

If a program change or termination results, it will be necessary to adjust the time spans of children with future review dates to allow 12 months of continuous coverage prior to termination or program change.

When caseload adjustments are needed to equalize the number of reviews due the following year, it is also permissible to set the time span for an early review to begin the month following the month the renewal form is received. The case should be documented when this action is being taken.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |505 Effective Month: December 2016 101.15.03 ADMINISTRATIVE RENEWALS An administrative renewal allows eligibility to be renewed based on reliable information contained in the case record and other more current information available to the regional office, such as current data secured from electronic data sources.

• An administrative review must be attempted on every case due for review except ABD cases with a resource test. ABD Medicare cost-sharing cases are renewed administratively, if possible. Exception: if eligibility for QMB, SLMB or QI was initially based on approval of an LIS application, the first annual review must be a full review via the pre-populated renewal process. After the first full review, attempt an administrative renewal for each subsequent review of a Medicare cost-sharing case.

• An administrative review is required annually for SSI-only cases in Long Term Care in COE-005. SSI-only reviews must be completed or, at a minimum, a redetermination contact must be registered, prior to the scheduled mailing of a pre-populated renewal form for the SSI-only case to prevent a pre-populated renewal form from being issued. For SSI-only reviews, the action needed is to verify the individual remains in the facility, check the SDX for any changes and attempt verification of any resources, such as a patient account or other type(s) of resources available to the SSI recipient.

• An administrative review is processed without contacting or requiring information from the MAGI household or Medicare cost-sharing recipient(s). If there is no known change in household circumstances and if all reported income types and sources can be verified through available electronic data sources, use current income verification from these sources to renew eligibility.

• If a MAGI or Medicare cost-sharing case can be approved using current information verified through electronic data sources, the recipient is notified of the approval. A pre-populated renewal form is not generated for administrative renewals.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |506 Effective Month: December 2016 ADMINISTRATIVE RENEWALS (Continued)

• If an administrative review does not result in an approval in the same program, a pre-populated form must be issued to allow the recipient to provide current information. It is possible to move a child from one Medicaid program to another Medicaid program based on an administrative review; however, a child cannot go from Medicaid to CHIP or CHIP to Medicaid.

• If a MAGI or Medicare cost-sharing recipient reports a change in response to an administrative renewal approval, document all changes on the “Administrative Review Contact Documentation” form located in the Appendix page by the same name. Attempt verification of a reported change through electronic data sources before requesting information directly from the recipient.

• Handle reported changes as a redetermination contact in the system. The appropriate approval or denial notice will be issued based on the outcome of the reported change.

• Automated mailings of pre-populated review forms take place on a schedule that is published annually and is based on the review due month. Administrative renewals must be registered as a redetermination contact with a time period pending before the scheduled mailing of a pre-populated form.

Every regional office must have a process in place to ensure administrative renewals are attempted as required prior to the scheduled mailing date for the system to issue a pre-populated review form.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |507 Effective Month: August 2017 101.15.04 PRE-POPULATED RENEWALS If a renewal of eligibility cannot be accomplished by an administrative review, a pre-populated review form is issued to the recipient displaying the information that is available to the agency. The renewal form is an initial request for information. Renewal due dates are included on the form which provides the recipient with time to respond and provide any necessary information specified on the form that is needed to renew eligibility. Renewal includes returning the signed renewal form. Renewal due dates are as follows:

• MAGI-related renewals have 30-days from the date the renewal form is issued;

• ABD renewals have 20-days plus time allowed for the issuance of a DOM-309, Second Request for Information, if needed.

The signed form and any paper verifications may be returned to the Division of Medicaid through any of the methods permitted for submission of applications.

MAGI pre-populated renewals are issued with known household composition and demographic data, current income information, tax and dependent status of each known household member and information on any health insurance coverage for household members. There is space on the form for the head of the household to make any needed changes to information reported on the form.

ABD pre-populated renewals are issued with known demographic and income information for each eligible individual or couple. There is space on the form for the individual or couple to make any needed changes to information reported on the form.

• Pre-populated renewal forms (MAGI and ABD) are issued by the system two months in advance of the review. For example, May renewals are mailed out to recipients in February and are due for completion/return to the Regional Office by March 31st. Reviews must be completed for adverse action by April 15th or the end of April, as appropriate.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |508 Effective Month: December 2016 PRE-POPULATED RENEWALS (Continued) • The case must have no open contacts or pending time periods by the published deadline in order for the system to generate a pre-populated renewal form. Any cases that are not in the appropriate status as of the date of mailing will be by- passed by the system making it necessary for the specialist to issue a pre- populated renewal form manually. If a renewal form is issued manually, the specialist must pre-populate the form will all known information required by the renewal form. • If a returned MAGI form is incomplete, meaning there is missing information or verification needed, attempt a telephone contact with the head of household to explain what is needed. For ABD incomplete renewals, use DOM-309 to request any missing verification(s). • If a returned form results in the reporting of new or additional information that was not previously reported and verification of the information is not possible for the regional office to obtain: o For MAGI cases, attempt a telephone contact to request the needed verification. If contact is unsuccessful, issue DOM-307 requesting the new or additional needed information in writing. o For ABD cases, use DOM-307 and, if needed, DOM-309 to request any new or additional information. • If a renewal form (MAGI or ABD) is not returned by the due date, attempt telephone contact with the recipient as a reminder that the form is due for completion and return to the regional office via mail, in-person or electronically. • When the ABD or MAGI recipient or head of household fails to provide all needed information, action cannot be taken to terminate eligibility due to failure to provide information without first attempting a telephone contact to inform the individual of the information needed and when it must be provided to prevent termination. All efforts to contact the individual must be documented in the case record. • Monthly and Weekly Redetermination Due Listings for both ABD and MAGI cases are available in the system to track and monitor cases due for review. Cases that are overdue for review are also part of these reports. • If needed information is provided after the applicable due date for renewal, refer to 101.16.12 “Requested Information Provided After Closure.”

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |509 Effective Month: December 2016 101.15.05 RETURNED MAIL FROM REDETERMINATIONS When an administrative approval notice or a pre-populated review form is returned by the post office, handle as follows:

• If mail is returned with a forwarding address, attempt a telephone contact to confirm the address. If a telephone contact is not successful or possible, update the address and re-route the mail. Document all contact attempts.

• If mail is returned without a forwarding address, attempt telephone contact(s) with the household to determine the current address. If all reasonable attempts to contact the household are exhausted and the current address cannot be obtained, terminate eligibility due to “unable to locate.”

• If the current address is subsequently obtained for an administrative review approval and it is determined the basis of eligibility in the administrative review was otherwise correct, i.e., no household or income changes, recipients may be reinstated with no loss of benefits if within 90 days of the date of closure. If new income or household information is reported, use the “Administrative Review Contact Documentation” form to collect information. If verification is needed, attempt to obtain it through available electronic data sources before requesting information from the recipient(s). Use a redetermination contact to conclude the review in the system.

• If the current address is subsequently obtained for a returned pre-populated form within 90 days of the date of closure, issue the form to the current address and allow 30 days for the form to be returned.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |510 Effective Month: December 2016 101.15.06 TIMELY PROCESSING It is important for redeterminations to be completed in a timely manner to prevent overdue cases. Since a recipient’s eligibility does not expire, benefits continue until the agency completes the review and an eligibility decision is made to either approve or terminate coverage. A review becomes overdue when more than 12 months have passed since the last eligibility determination. It is the responsibility of regional office staff to ensure reviews are processed timely.

When to Begin Processing a Review

It is permissible to begin the review process as early as the 10th month of a 12- month eligibility period or no more than 2 months early. However to ensure timeliness, the review process must begin no later than the month prior to the review month. This means for a case with a review due date of August, the redetermination process may begin as early as June, but must begin no later than July.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |511 Effective Month: December 2016 101.15.07 TIMELY AUTHORIZATION The approval of a Medicaid redetermination is timely if it is authorized by the last day of the month in which the review is due. If Medicaid or CHIP benefits are terminated, the action must be authorized no later than the adverse action deadline in the review month to be effective the following month.

When a redetermination closure is not authorized by the adverse action deadline in the review month, the case or individual is out of certification. However, an improper payment report is not required for the untimely closure. Ineligibility must exist for another reason for an improper payment report to be prepared.

Adverse Action Deadlines

The adverse action deadline is the 15th of the month in order to allow 10-days advance notice plus 5 days mailing time. Action must be taken by the adverse action deadline in the review month if coverage is to be terminated at the end of the review month.

If Medicaid or CHIP termination action is authorized by the 15th of the month in which the review is due, the termination is effective at the end of the review month. An exception is February when the adverse action deadline is the 13th.

NOTE: Adults are not guaranteed 12 months of coverage. If termination is appropriate, the specialist will take action to terminate an adult’s eligibility for the earliest possible month. However, coverage must be terminated no later than the adverse action deadline in the last month of the review period for the redetermination closure to be timely.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |512 Effective Month: December 2016 101.15.08 EXPARTE REVIEWS Any recipient under review who is losing eligibility in one category of assistance is entitled to have eligibility reviewed and evaluated under any/all available coverage groups. The term “exparte review” means to review information available to the agency to make a determination of eligibility in another coverage group without requiring the individual to come into the office or file a separate application.

When to Complete an Exparte Determination For an exparte determination to be made, the specialist must be in the process of making a decision on a current application, review or reported change. If the specialist is denying or closing for failure to return information or failure to complete the review process, an exparte determination is not applicable.

Example: Jane Doe’s CHIP eligibility will terminate because the family reports she is now covered under other health insurance. The specialist must review the record to see if it contains information which indicates the child has potential eligibility under another coverage group. Example: Recipient Tom Smith failed to comply with the annual review requirement and his eligibility must be terminated. The specialist does not complete an exparte determination.

Basis for the Exparte Review The decision of whether the recipient is eligible under a different coverage group must be based on information contained in the case record. This may include income, household or personal information in the physical record which indicates the ineligible adult or child has potential eligibility in another coverage group. It also includes information received through electronic matches with other state/federal agencies such as a disability onset date or prior receipt of benefits based on disability.

Obtaining Information to Make the Determination When potential eligibility under another coverage group is indicated, but the specialist does not have sufficient information to make an eligibility determination, the recipient must be allowed a reasonable opportunity to provide necessary information.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |513 Effective Month: December 2016 EXPARTE REVIEWS (Continued) Using DOM-307, the specialist will ask the recipient to provide verifications needed to determine eligibility in the new category. If the individual is an ABD recipient potentially eligible in an MAGI category or vice versa, the request will include completion of the appropriate application form to collect required program information. An in-person interview is not conducted in the exparte review process even for a program that normally requires an interview.

Eligibility Decision If the individual is subsequently determined to be eligible in the new category, the approval must be coordinated with termination in the current program to ensure there is no lapse or duplication in coverage. However, if requested information is not provided or if the information clearly shows that the recipient is not eligible under another category, eligibility in the current program will be terminated with advance notice.

During the advance notice period, the recipient is allowed time to provide all requested information to determine eligibility in the new program, provide information which alters the decision to terminate benefits in the current program or request a hearing with continued benefits. The specialist must take prompt and appropriate action to reinstate benefits when the recipient either provides all requested information needed to determine eligibility in another category, provides information which changes the termination decision in the current program, or requests a hearing with continued benefits during the advance notice period.

NOTE: When the recipient is determined ineligible in the new category, he does not have to repay the benefits he received while the eligibility determination was in process. However, if benefits are continued pending a fair hearing decision and the outcome is not favorable to the recipient, he is liable for repayment of the cost of services furnished solely because of the continuation of benefit provision.

Requested Information Provided After Closure If the recipient subsequently provides all of the information needed to assess eligibility in the new program within 90-days of termination, the case should be handled in accordance with “Requested Information Provided After Closure,” described in 101.16.12.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |514 Effective Month: December 2016 EXPARTE REVIEWS (Continued) Example: A CHIP review is due in May. On May 10th, the specialist determines the children’s eligibility will terminate because of excess family income. She completes an exparte review of the case record and notes the SVES response for one child indicates the child has prior SSI eligibility. Since information available to the agency indicates a potential disability for this child, the specialist determines the child must be evaluated for another coverage group before her CHIP eligibility can be terminated. Since the exparte review does not indicate potential eligibility in any other coverage group for the other children, the specialist completes the closure action for them, leaving eligibility open for the potentially eligible child. She documents the case to support the action. The specialist issues a 307 requesting a completed ABD application form and other information to determine Medicaid eligibility based on disability. The family does not respond to the request. On May 23rd after the 307 request period has expired, a 309, Second Request for Information, is issued. The family subsequently provides the required information. CHIP benefits remain open while the eligibility determination process continues. On August 10th, the child is determined eligible in the Disabled Child Living at Home program. Her CHIP eligibility is terminated effective August 31st and ABD Medicaid eligibility is authorized effective September 1st in the system.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |515 Effective Month: December 2016

101.15.09 SSI REVIEWS REQUIRED FOR SSI TERMINATIONS The SSI review process is a type of exparte review. When individuals are terminated from SSI due to income and/or resources, they are systematically issued an SSI Termination Notice and an SSI Review Form, DOM-300B, upon receipt of SDX notification of termination. This form is to be completed and returned to the appropriate regional office if the recipient wants to apply for continued Medicaid coverage and is eligible under one of the coverage groups described in the SSI Termination Notice. A signed form is required. The form may be complete or incomplete. If incomplete, the specialist will take the necessary steps to obtain needed information. NOTE: The SSI Termination Notice advises the individual to complete and return the form to the regional office with 10-days from receipt of the notice; however, allow the form to be returned prior to the date of the SSI closure. SSI/Medicaid closures are effective for the end of current month only if the SSI transaction to close SSI/Medicaid is received by the 10th day of the month; otherwise, the closure is effective at the end of the following month. If the DOM-300B is not received timely, the individual can apply at any time using the full ABD application form. An in–person interview is not conducted, even if the program is one that normally requires an interview. However, all necessary factors of eligibility must be verified, such as disability, residency, utilization of benefits, etc. In addition, if other health insurance coverage is indicated on the 300B, TPL information must also be obtained. SSI redeterminations have a 30-day processing standard, unless a DDS determination must be obtained.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |516 Effective Month: December 2016 101.15.10 RECEIPT OF REGULAR REVIEW FORMS

MAGI-related and ABD regular reviews may be submitted to a regional office is any of the means allowed for filing an application. Receipt of a redetermination or review form includes pre-populated forms that were issued by the system or manually, SSI review forms, and ABD review forms issued systematically or manually. These forms may be received in any of the following ways:

By mail in any regional office or in the central office. If received in the incorrect RO, forward to the correct RO in the same manner as an application.

By fax. An original signature is not required. In-person in any regional office, out- stationed site or other location where eligibility staff are on official duty. If assistance is requested in completing the renewal form, assistance must be provided on the day the individual comes into the office or other location.

By telephone. Assistance completing the review form must be offered if needed.

Unless the telephone review is recorded, the review form must be mailed to the individual to sign and return to the agency.

Review forms are not offered on-line and cannot be completed and returned to the agency on-line.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |517 Effective Month: December 2016 101.15.11 DISPOSITION OF A REGULAR REVIEW – ABD AND MAGI

ABD and MAGI redeterminations are completed administratively, if possible, or by use of a pre-populated review form that is issued either systematically or manually, as discussed above. When the form is returned and all information subject to change has been evaluated and a decision is reached regarding continuing eligibility, the following actions will be authorized:

101.15.11A APPROVAL OF A REGULAR REVIEW When the ABD recipient/representative or MAGI head of household has complied with all redetermination requirements and provides required verifications, the specialist will review the eligibility criteria; ensure appropriate documentation is filed in the case record and input the data into the system for an eligibility decision. All redeterminations are submitted for supervisory review and authorization. When eligibility will continue at the same level, a new review due date is established and an approval notice issued to the recipient or head of household when benefits are authorized.

101.15.11B REDUCTION OR TERMINATION OF BENEFITS Advance notice of adverse action is required, if the eligibility decision results in termination of benefits for all or some members of the case. During the adverse action period, the recipient or head of household is allowed time to fully comply with unmet redetermination requirements, provide information or verification that will alter the adverse action decision or request a fair hearing with continued benefits.

For MAGI-related cases, adverse action is required to terminate benefits for one or all members of the household.

For ABD cases, adverse action is required in all of the following situations:

• Termination of benefits; • Conversion to a reduced services coverage group; • Termination of a nursing facility per diem payment.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |518 Effective Month: December 2016 101.15.11B REDUCTION OR TERMINATION OF BENEFITS (Continued) The system is not programmed for the case to remain open during the adverse action period; however, eligibility staff must treat the case as if it is open until the period has ended. During this period if the ABD recipient or MAGI head of household subsequently complies with all redetermination requirements or provides information which changes the negative action, eligibility must be reinstated. If the client requests a hearing, with continued benefits, the case must be promptly reinstated. Specialists must take prompt action on the information provided during the advance notice period. Timely action must be taken to prevent a break in coverage, whether the client takes action within the first few days of the adverse action period or on the final day. ABD Example: The recipient did not provide income verification needed for the May redetermination. The closure is authorized on May 10th and advance notice is mailed to the recipient advising that eligibility will terminate effective May 31st. On May 18th, within the advance notice period, the verification is received in the office. The specialist takes action to process the case as a reinstatement and determines eligibility using the current income. The supervisor then reviews the action and authorizes the eligibility decision. Appropriate notice is issued to the client and there is no break in coverage. MAGI Example: The head of household failed to comply with redetermination requirements for a May redetermination. The case was closed on May 15th effective May 31st. On May 29th partial verification is provided; however, all information needed to process the case is not provided. A reinstatement contact is registered for May 29th. A 307 is issued for the information and 30-day processing is applicable.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |519 Effective Month: December 2016 101.15.12 REQUESTED INFORMATION PROVIDED AFTER CLOSURE When an ABD or MAGI case is closed due to failure to provide information, a reapplication is not required if the following are met:

• The recipient or head of household subsequently provides all information necessary to complete the redetermination; and

• The case has been closed for 90-days or less at the time the information is provided.

Example: The recipient did not provide income verification needed for the May redetermination. The closure is authorized on May 10th effective May 31st. If the information is furnished by August 31st, eligibility can be determined using the reinstatement process. After August 31st, a reapplication must be filed. NOTE: If a MAGI-related child was not due for review when action was taken to terminate other household members who were due for review, the 90-day provision described above does not apply since any child(ren) not due for review could not have been closed with a future date. Children undergo a full review at the time end of their 12-month protected period.

The specialist is responsible for taking action within 48 hours of receipt of the information to register the reinstatement in the system. The case will be processed based on the most recent application and/or renewal form. There is no requirement to obtain an updated signature on the application form. Refer to the Reinstatement policy for a complete discussion of the process required to reinstate eligibility.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |600 Effective Month: December 2016 101.16 SPECIAL REVIEWS A special case review is completed when changes occur between regular reviews, which may result in adjustments to eligibility or benefit level. A special case review is not a full review. Instead the case (or an individual) is evaluated to consider the impact of the changed information. Factors unrelated to the change are not re-verified as part of a special review. Example: A COE-075 adult recipient reports three months after her regular redetermination that she has a part-time job. The children in the case have income from Social Security which was last verified at the regular review. The Social Security income is not subject to re-verification since it is not part of the reported change. A special review of eligibility is required when: • The recipient reports a change in circumstances which could affect eligibility and benefit level; • Information is received from any other source which could affect eligibility and benefit level; • Potential changes in eligibility are indicated by information available to the agency. The special review process may result in termination of benefits, benefit reduction or adjustments to Medicaid Income. It may also involve procedural changes, i.e., updating or correcting case information with no impact on eligibility or benefits. Special reviews are handled differently, depending on the impact the change may have on eligibility and is discussed below. 101.16.01 RECIPIENT REPORTING REQUIREMENTS Recipients must report required changes within ten days of the date the change becomes known. Changes may be reported in person, by telephone, by mail or fax to the agency. A change is considered reported on the date the report of change is received by the agency. If an individual fails to report timely or the agency fails to take timely action, causing the recipient to receive benefits to which he is not entitled, the specialist will take steps to report an overpayment.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |601 Effective Month: December 2016 101.16.02 CHANGE REPORTING REQUIREMENTS - ABD The following types of changes must be reported by ABD recipients within 10 days of the date the change becomes known: • Changes in address in or out of state; • Changes in marital status; • Changes in income for the recipient and/or spouse; • Change in any type of policy that would pay for medical services, such as health insurance, indemnity policies, major medical policies, CHAMPUS or legal settlements; • Changes in a recipient’s disability which would affect his Medicaid eligibility; • Changes in living arrangements, such as a long term care (LTC) recipient entering a hospital or a nursing home, leaving a hospital or a nursing home, moving from one medical facility to another; • Changes in resources, i.e., recipient buys, sells, gives away or receives an asset or any part of an asset; and. • Changes in health insurance premiums for LTC recipients.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |602 Effective Month: December 2016 101.16.03 CHANGE REPORTING REQUIREMENTS – MAGI PROGRAMS The following changes must be reported by MAGI-related recipients within 10 days of the date the change becomes known. All MAGI Recipients • Changes in address in or out of state; • Changes in any type of policy that would pay for medical services, such as health insurance, indemnity policies, major medical policies, CHAMPUS or legal settlements. COE-075 Adults • Increases in earnings or other income; • Changes in marital status; • Changes in household, such as spouse or parent entering or leaving the home and/or children entering or leaving the home. COE-075 Adults on Extended Medicaid • Termination of employment when new or increased wages caused ineligibility; • Termination of spousal support income when new or increased spousal support caused ineligibility. Pregnant Women • Change in the verified due date, i.e., earlier delivery/termination date or later due date than originally verified. Child Only Cases • Children leaving the home (includes institutionalization, death, foster care, etc.); • Uninsured CHIP child becoming covered by creditable health insurance; • CHIP child becoming pregnant.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |603 Effective Month: December 2016 101.16.04 PROCEDURAL CHANGES – ABD and MAGI Procedural changes include: • Name corrections or changes; • In-state address corrections or changes; • Change or appointment of a guardian or conservator; • Case transfers between regional offices; • Program transfers such as a disabled or blind recipient turns age 65, becoming an aged client. NOTE: In the system, name, address, SSN, DOB, marital status, race and gender can be changed or corrected on a processed time span.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |604 Effective Month: December 2016 101.16.05 TAKING ACTION ON REPORTED CHANGES Specialists must follow up on information which is reported by the recipient or otherwise becomes known to the agency to determine if the information is a reportable change. If the change is not reportable, the information will be considered at the next regular review. For instance, an income increase reported by the parent of a Medicaid or CHIP child is not a reportable change because of the continuous eligibility provision for children. The impact of an increase in parental income will be considered at the next review. However, if the parent reports an eligible child has moved from the state, that is a reportable change which must be acted upon. Action on a reportable change must be initiated no later than 10 working days from the date the change becomes known to the agency to determine its impact on eligibility and benefit level. NOTE: It is imperative that timely action be taken on reported changes to prevent agency error. For instance, recipients frequently report address changes. Failure to take prompt action on these changes not only results in inconvenience to the recipient, but also may lead to benefits being terminated in error when notices are mailed to the wrong address. If verification of a reportable change is needed from the recipient, DOM-307 will be issued to provide written notice of the required information and due date. DOM-309 will be issued, when applicable, to ABD recipients. Action is taken on changes as follows: • Reported changes with the likelihood that eligibility will be adversely affected require development, which may mean a request for additional information is needed. Failure by the MAGI head of household or ABD recipient or representative to respond to needed information will result in termination of eligibility for any adult(s) affected by the change. Changes can include, but are not limited to, the report of a marriage with additional household income to consider, a new job for a household member or any type of change indicating an additional source of income.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |605 Effective Month: December 2016 TAKING ACTION ON REPORTED CHANGES (Continued) • A negative change reported during a review period that affects eligibility for adult(s) is handled at the time of the reported change; however, it is not permissible to take punitive action on the children in a case due to action being taken for the adult’s eligibility. This includes not setting future termination dates for the children at the end of their 12-months of continuous eligibility. Children must be reviewed so their eligibility is assessed at each annual review. For example, an adult reports marriage and is terminated during the review period because spousal wages were requested but not verified. The adult’s eligibility is terminated. A future closure would not be set for the children. The child’s eligibility must be reviewed at the next annual review. If information needed at the time of the annual review is not provided, the children’s eligibility would be terminated as a result of the annual review. • If there is a case change, such as the addition of a parent, that results in information that must be requested to confirm the parent’s eligibility, do not require updated information for a child’s eligibility. Handle the child’s eligibility at the next annual review. • Reported changes that will not likely affect eligibility for the household should be developed but if a request for additional information yields no response, it is not permissible to terminate eligibility for a failure to respond to the request. Instead, follow up at the next review. These types of changes may include a change of address for the household when a move out of state is not indicated, loss of an income source to the household, the death of a child’s parent or other types of changes that would not result in a loss of eligibility. • Reported changes or actions taken during a review period can affect one or more household members but not the entire household. The option to perform an early review can be offered but cannot be required for a child’s eligibility. • A change during the review period that results in updated information on all household members can result in eligibility being extended for the household. For example, during the review period a parent applies and is added to the case. All household income is updated and verified. It is permissible to extend eligibility for a new 12-month review period for the children under these circumstances.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |606 Effective Month: December 2016 Documenting the Case Record

The case record/case narrative must reflect the following information about the reported change:

• Who reported the change; • When the change was reported; • How the change was reported; • When action was initiated on the change; • What was used to verify the change; and • What action was taken in regard to the verified information.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |700 Effective Month: December 2016 101.17 REINSTATEMENTS Certain situations require a reinstatement of services, which means either eligibility is restored or Medicaid income is corrected for a prior period. Both types of reinstatements are completed without requiring that a new application be filed on behalf of the recipient. A reinstatement is in order in the following situations, as applicable, to ABD and MAGI recipients via a Reinstatement contact in the system. 101.17.01 INFORMATION PROVIDED PRIOR TO EFFECTIVE DATE OF CLOSURE If the recipient provides information that changes the adverse action decision or fully complies with unmet requirements prior to the effective date of the closure, benefits must be reinstated to ensure no loss of benefits, if the recipient remains eligible. If the information provided does not change the adverse action decision, no further action is required. If advance notice of Medicaid and/or CHIP benefit reduction or termination was not issued as required, benefits must be reinstated back to the date of closure at the time the error is discovered, regardless of whether the client is currently eligible. After benefits are reinstated, advance notice would then be issued to close the case in order to meet the advance notice requirements. Close the case at the end of the advance notice period.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |701 Effective Month: December 2016 101.17.02 90-DAY REINSTATEMENT PERIOD FOR MAGI AND ABD RENEWALS A 90-day reinstatement period is required for MAGI (including CHIP) and ABD renewal/review closures to allow eligibility to be reinstated retroactively to the effective date of the closure if the recipient is otherwise eligible. The 90-day reinstatement period, defined as 90-days from the effective date of the closure, allows Medicaid or CHIP eligibility to be reinstated without requiring a new application or updated signature. The 90-day reinstatement period applies to renewal/review closures due to: • Failure to return the MAGI or ABD renewal form, or • Failure to comply with renewal requirements by not providing requested information issued in writing on a DOM-307, Request for Information (and DOM-309, Second Request for Information, for ABD purposes). The 90-day reinstatement period is not associated with other types of reinstatements described in this section that either have no time limits for initiating a reinstatement or may have different time limits. These types of reinstatements are the result of corrective action needed, hearing decisions, known temporary closures for ABD and locating a recipient whose whereabouts were previously unknown.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |702 Effective Month: December 2016 101.17.02A RENEWAL CLOSURES REQUIRING REINSTATEMENT Reinstate a MAGI or ABD case that closed at renewal when either of the following conditions exists: • The case closed due to failure to return the renewal form and a signed form (complete or incomplete) is returned within the 90-day period following the effective date of closure; or, • The case closed due to failure to provide needed information and the requested information is provided in full or in part within the 90-day period following the effective date of closure. Effective Month of the Reinstatement The effective month of the reinstatement is the month following the month of closure. The exception to this rule is if there is a future closure date on file. For future closures, reinstate no earlier than the next calendar month after the current month. For example, if the reinstatement action is taken in July for a child with a closure date at the end of September, reinstate the case with a time period starting no earlier that August 1st. Requesting Additional Information to Process the Reinstatement If the renewal form is incomplete or the information provided is incomplete, attempt to handle these issues by telephone contact, if possible. If not possible, issue a DOM-307, Request for Information (and DOM-309A for ABD, if needed), specifying what is needed to comply with the renewal process and allow 12 days for the information to be returned. • If requested information is not provided, no further contact with the individual is required unless the information needed is provided during any remainder of the 90-day period. Close the reinstatement contact, delete the time period and document the case narrative.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |703 Effective Month: December 2016 Requesting Additional Information to Process the Reinstatement (Continued) • If all information is provided, take action to process the case: o If eligible, approve using the reinstatement contact providing all eligible coverage. o If ineligible due to an eligibility-related reason, i.e., over income, handle as follows:  Cancel the reinstatement contact,  Set an application contact,  Use the 1st day of the month following the closure month as the application date. For example, if the case originally closed at the end of June (06/30), use the 1st of July (07/01) as the application date and the time period begin date.

101.17.02B RENEWAL REINSTATEMENT NOT REQUIRED A reinstatement is not required for a renewal closure if the renewal form is returned unsigned.

• File a copy of the unsigned form in the case and document the case accordingly,

• Return the original unsigned form via a manual 307, Request for Information for both MAGI and ABD renewals, advising the individual the attached form must be signed (Note: a 309 is not issued in this instance if the form is not returned).

• If the signed form is subsequently returned within the 90-day period, handle as instructed in “Renewal Closures Requiring Reinstatement” described above.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |704 Effective Month: December 2016 101.17.03 CORRECTIVE ACTION At the time the agency becomes aware of an error which affects eligibility or level of benefits, action must be initiated to correct the error. Immediate corrective action is required to prevent further error. In some instances, it may also be necessary to correct an error retroactively into prior months. • When corrective action into prior months adversely affects the recipient, meaning the error caused the client to be totally ineligible or eligible for fewer benefits, DOM-354, Improper Payment Report, or DOM FCC-354, Improper Payment Report Families, Children and CHIP, is prepared. • When corrective action into prior months favorably affects the client, meaning the client was eligible or eligible for more benefits, the corrective action is handled through reinstatement. When the agency has denied or terminated eligibility in error or reduced benefits in error for reasons such as failure to act on information present in the record or provided during the advance notice period, misapplication of policy, miscalculation of income or resources, untimely processing, etc., benefits must be reinstated retroactive to the month the error occurred.

The discovery source for the error may be: o Case reviews; o Applicant or recipient complaints; o Recognition by the specialist; o Other sources having knowledge of the error.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |705 Effective Month: December 2016 101.17.04 CONTINUATION OF BENEFITS AND HEARING DECISIONS When the client makes a timely hearing request during the advance notice period, benefits will be continued at the same level through the reinstatement process until a hearing decision is reached. When a decision, granting eligibility or increased benefits is rendered as a result of a state or local hearing, the regional office may be required to reinstate eligibility or when appropriate correct Medicaid Income, retroactive to the date decided by the hearing official. If benefits were continued in an active case pending the hearing decision, reinstatement may not be required unless the decision at the hearing is to increase the level of benefits in effect prior to the hearing. 101.17.05 TEMPORARY CASE CLOSURE When it is known that a client will be ineligible for two months or less, the closure is processed in the usual manner; however, at the end of the temporary period, the case may be reinstated without completing new eligibility forms necessary for reapplication. The case record will show:

o The exact length of time during which ineligibility will exist; o The date the recipient will be eligible again; o The reason for the temporary ineligibility.

In this situation a break in eligibility correctly exists; therefore, it is necessary to adjust the eligibility begin date to reflect the most recent eligibility begin date.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |706 Effective Month: December 2016 101.17.06 WHEREABOUTS UNKNOWN As indicated previously, eligibility must be terminated if a client’s whereabouts remain unknown after the agency has (1) received returned mail with no forwarding address and (2) made reasonable efforts to locate the recipient. If the client’s location subsequently becomes known during the time he is eligible, benefits will be reinstated. For a child who has continuous eligibility, Medicaid and/or CHIP benefits must be reinstated with no loss. For an adult, the specialist must determine eligibility for each month that the adult recipient’s whereabouts were unknown and reinstate for any period he would have been eligible.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 800 Effective Month: December 2016 101.18 OTHER CHANGES – ABD PROGRAMS 101.18.01 CHANGES IN MEDICAID INCOME The amount of income an institutional client must pay to the nursing facility toward the cost of his care is known as Medicaid Income. Changes in income, marital status or non-covered medical expenses will either increase or decrease Medicaid income. The effective dates of such changes are determined as follows: Decrease in Medicaid Income A change which results in a decrease in Income is effective the month in which the change is reported or becomes known to the agency. For example, a decrease in income reported any time in the month of June will be effective as of June 1. The notice issued to the client and to the facility will specify June 1. Increase in Medicaid Income A change which results in an increase in Medicaid Income requires advance notice to the client advising of the increase. However, advance notice for Medicaid Income increases is based on issuing notice 10 days before the date Medicaid makes its payment to the facility. A nursing home cannot submit a claim for any month’s payment until the first day of the following month. Payment is then made to the facility on the first Monday following receipt of the claim. This means the specialist has 10 days before Medicaid makes its payment to a facility to increase Medicaid Income for the current month. Since payment schedules may vary, policy governing increasing Medicaid Income in the current month is based on whether advance notice can be issued 10 calendar days before the first of the following month. Example: An increase in a recipient’s income is discovered on October 10, Medicaid Income can be increased effective October 1 if advance notice of the increase is issued no later than October 21. NOTE: If a state or local hearing is requested within the advance notice period, the increase cannot be effective until the final hearing decision is rendered.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 801 Effective Month: December 2016 CHANGES IN MEDICAID INCOME (Continued) Temporary Decrease in Medicaid Income When Medicaid Income is temporarily decreased due to the allowance of a deduction, i.e., health insurance premium or other non-covered medical expense, and Medicaid Income is subsequently returned to the amount previously in effect, this action is not considered an increase in Medicaid Income subject to advance notice. When the client is notified of the allowance of the deduction, the notice should also advise that Medicaid Income will return to the previous amount and specify the amount and date Medicaid income will resume. In any instance where Medicaid Income does not revert back to the amount in effect prior to allowance of a deduction, an increase would require advance notice. Increase in Medicaid Income Combined with a Closure In instances where income is counted in the month received, but receipt of the income also renders the client ineligible, the excess income is included in the Medicaid Income computation provided there are 10 calendar days left in the month of receipt to allow for advance notice. In addition to increasing Medicaid Income for the month of receipt, the case is also scheduled for closure. Example: A client receives a lump sum VA payment of $4000 in December which is reported to the regional office on December 12. Action is taken to include the $4000 as income for December for Medicaid Income purposes. On December 19, notice is issued to allow advance notice of the increase in Medicaid Income effective December 1 and closure for December 31 due to excess resources for January. The amount of Medicaid Income due for the month will be the actual shown on the notice or the Medicaid reimbursement rate for the facility, whichever is less. The client or representative must be advised to contact the facility to obtain the lesser of the two amounts.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 802 Effective Month: December 2016 Temporary Increase in Medicaid Income When excess resources are not an issue, but receipt of additional income results in the monthly income total being over the income limit for LTC, the case will remain open if, for whatever reason, there is not time to allow advance notice of closure. However, if there are 10 calendar days left in the month, Medicaid Income must still be increased to the amount of that month’s income or the Medicaid reimbursement rate for the facility, whichever is less. The client or representative must be advised to contact the facility to obtain the lesser of the two amounts. For the following month, eligibility will continue. The additional income will be removed from the Medicaid Income calculation and Medicaid Income will return to the amount in effect prior to the temporary income increase. Example: A client receives a lump sum VA payment of $2500 in December which is reported to the regional office on December 21. The office became aware of the income too late to close the case; however, action is taken on December 21 to include the $2500 as income for December for Medicaid Income purposes. On December 21, notice is issued to allow advance notice of the increase in Medicaid Income effective December 1. The lump sum did not cause resources to exceed the limit; therefore, eligibility continues. The income is removed from the Medicaid Income calculation and Medicaid income returns to the prior amount effective January. 101.18.02 CHANGE TO A REDUCED SERVICE COVERAGE GROUP Changing from a full service coverage group to a reduced coverage group requires advance notice before the change can be effective the following month. It is not possible to change an active full service case to a reduced service coverage group such as QMB, SLMB, or QI in the system for the following month after the established deadline dates for advance notice.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 803 Effective Month: December 2016 101.18.03 WOMEN IN HEALTHIER MS WAIVER OR MEDICARE COST-SHARING GROUPS TRANSITIONING TO COE-088 FOR PREGNANCY AND POST- PARTUM ELIGIBILITY The Healthier MS Waiver (HMW) and Medicare Cost Sharing eligibility groups do not cover pregnancy-related services. If a woman is active in the HMW or as a QMB, SLMB or QI and reports that she is pregnant and needs pregnancy-related coverage, take the following action: • Obtain her expected due date, • Using information from her ABD application or last review form, use non-filer MAGI household composition and budgeting rules to determine her eligibility for COE-088, • If eligible, transition her to COE-088 for the duration of the pregnancy and post- partum period. At the end of the post-partum period, the system will automatically transfer the woman back to her original ABD COE. If her annual review is due or overdue, give priority to completing the redetermination of the woman’s ABD eligibility. • If ineligible for COE-088 using non-filer rules, contact the ABD recipient to confirm whether the use of non-filer rules is appropriate. If the recipient is a tax filer or dependent of a tax filer, apply filer rules as appropriate to determine eligibility for COE-088. o If eligible using filer rules, transition ABD recipient to COE-088 for the duration of the pregnancy and post-partum period. At the end of her post-partum period, the system will automatically transfer her back to her original ABD COE. If her annual review is due or overdue, give priority to completing the needed redetermination of ABD eligibility. o If ineligible using filer rules or if filer rules do not apply and the ABD recipient is ineligible using non-filer rules, issue a manual DOM-305, Notice of Action, advising the ABD recipient that she is not eligible for Medicaid as a pregnant woman but that she remains eligible in her original ABD coverage group.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 900 Effective Month: December 2016 101.19 OTHER CHANGES – MAGI PROGRAMS 101.19.01 TRANSITIONING THE PREGNANT CHIP CHILD TO MEDICAID COE-088 For most children, program changes are effective only at review because of the continuous eligibility provision for children. However, when the agency becomes aware that a CHIP child is possibly pregnant, a special review must be completed to verify pregnancy/due date. There is no need to determine if the minor is eligible for Medicaid coverage as a pregnant woman, because pregnant minors have income exemptions that assure eligibility. If pregnant, enter the due date in the system, process eligibility and the child will transition from CHIP to COE-088 Medicaid for the duration of the pregnancy and post-partum period. However, if the office learns of the change too late, i.e., the minor is at the end of her pregnancy or has already delivered, no action is taken to change the program. The program transition from CHIP to Medicaid is not an adverse action. If action is taken by the end of the current month, CHIP will terminate at the end of the current month and the pregnant minor will move to Medicaid COE-088 the following month. The head of household is issued a notice which contains the following information about the child’s eligibility: • Date the pregnant child will be removed from CHIP; • Date the child will be eligible for Medicaid as a pregnant woman; • The verified delivery date and the requirement to report an earlier or later date; • Date the child will become ineligible for Medicaid as a pregnant woman; • Date CHIP eligibility will resume; • The child’s review due date; • Information about coverage for a 2-month post-partum period; • The deemed eligible provision for children born to Medicaid-eligible women.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 901 Effective Month: December 2016 TRANSITIONING THE PREGNANT CHIP CHILD TO MEDICAID COE-088 (Continued) If there are months remaining in CHIP at the end of the post-partum period, the system will return the child to CHIP and the review should be completed when due. If the pregnant minor’s review comes due while she is on COE-088, the review will be completed. If the child is eligible for full Medicaid, action can be taken immediately to change the child from COE-088 to the appropriate MAGI coverage group for a child under age 19. If the child continues to be CHIP- eligible at review, the new 12-month eligibility period is effective at the end of the post-partum period. 101.19.02 WOMEN IN THE FAMILY PLANNING WAIVER (FPW) TRANSITIONING TO COE-088 FOR PREGNANCY AND POST-PARTUM ELIGIBILITY The Family Planning Waiver does not cover pregnancy related services. If a woman is active in the FPW and reports that she is pregnant, obtain her expected due date and enter it into the system so that she will transition to COE-088 for the duration of her pregnancy and post-partum period. Since the FPW uses non-filer rules to determine eligibility and non-filer rules would apply to the transition determination, there is no requirement to do a new or updated determination. At the end of the post-partum period, the system will return her to the FPW.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 950 Effective Month: March 2018 101.20 APPLICATION AND REVIEW SUMMARY CHART ACTION POLICY REQUIREMENT PROCEDURAL REQUIREMENTS Filing an Application, Submitting a Renewal Form, and Reporting Changes Means of submission: • In-person at any location where eligibility staff are on official duty • By mail to the agency, RO or Central Office (CO) • By fax to the agency (RO or CO) • Applications may be submitted on- line at www.medicaid.ms.gov. • By telephone – If signature is not telephonically recorded, must obtain a signature. Applications & Renewal Forms must be signed but an original signature not required. Telephone signatures are recorded versions. Who Can File an Application • Adult applicants • Certain minors (pregnant, married, living independently, applying for own children) • Parent with primary physical custody or either parent if true joint custody exists • Caretaker relative • Authorized, designated or legal representative

If application filed by incorrect person, do not deny; get signature of correct person.

Applications must be signed to be valid. Authorizing a Representative (types allowed) 1) Authorized Representative – applicant or recipient designates in writing. Can be a person or organization. Limits can be placed on rep’s rights to act. 2) Self-Designated Rep – must be an individual except for owner/operator of state owned LTC facility. Rights are not limited. Applicant must be incapable of designating authorized rep. 3) Legal Rep – legally appointed by court or other legal document (such as POA) and must be legally authorized to make healthcare decisions for applicant/recipient. Can be an executor of deceased applicant’s estate. MAGI application form used to designate authorized rep for MAGI cases. DOM-302A required for ABD authorized rep.

Self-Designated requires DOM- 302B; Legal rep requires DOM- 302C.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 951 Effective Month: March 2018 Filing Date of an Application The date a signed application is filed or received by the agency (RO or CO) by any means of submission for filing an application.

The date received by DOM or the FFM is the date filed. Medicaid Applications Filed Outside of DOM 1) SSI applications, 2) Children in the custody of DCPS who are certified as eligible by DCPS, 3) Medicaid or CHIP applications filed with the FFM and transferred to DOM, 4) LIS applications filed with SSA and transferred to DOM, 5) HPE applications filed with qualified hospitals and transferred to DOM. DOM determines eligibility for FFM, LIS and HPE applications. RO with Responsibility RO that serves the county where at-home recipients live is responsible for the case. Long term care cases are handled by RO that serves the county where the facility is located. Combo MAGI/ABD cases with one in a facility is handled by RO where facility is located.

Requiring an In-Person Interview ABD institutional (long term care & HCBS) require an in-person interview at the time of application only. Waive the in-person interview if no rep and applicant is physically unable to appear at any location. Utilize a telephone interview. Any applicant (MAGI or ABD) may request in- person assistance with applying.

Timely Processing of Applications (SOP or Standard of Promptness) • 45 days for MAGI and ABD if no DDS decision needed. • Applications filed with FFM have a SOP beginning with date received by DOM; filing date is date filed with FFM. • 90 days for ABD if DDS decision needed.

Days are counted from date of filing application to decision date, except those filed with FFM.

Making an Eligibility Decision Verification of eligibility factors comes from data available from electronic data sources and/or the applicant. If data is unavailable from data sources or if applicant provided information is inconsistent, verify independently, which includes obtaining from applicant.

Case documentation is required to support an eligibility decision. Use the Case Narrative or document within the case record.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 952 Effective Month: March 2018 Issuing Requests for Information (RFI) ABD applications utilize a 307 (1st RFI) and 309 (2nd RFI). If additional time is requested, hold to end of SOP applicable. MAGI applications require direct contact 1st, then utilize a 307 (1st RFI). If additional time is requested, hold to end of 45 days.

Refer to “Reasonable Efforts to Assist All Applicants” to avoid multiple denials of eligibility when the applicant is incapable or rep is unwilling to provide needed information. Compliance After Denial If MAGI or ABD applicant fully complies by providing needed information by the end of the month following the month of denial, use denied application and application date and reinstate the application.

MAGI Application Indicates Possible ABD Eligibility If a MAGI applicant indicates possible disability, issue the ABD DOM-300 & request only information not available through MAGI process. A signed ABD application is required. FFM applicants indicating disability are sent a Non- MAGI letter that must be signed & returned to start ABD process.

Determining Beginning Dates of Medicaid Eligibility If all factors of eligibility are met, the begin date is: • 1st of month of application, or • 1st day of the 1st, 2nd or 3rd month prior to the month of application. • QMB eligibility begins no earlier than the month following the month of approval. • HPE eligibility begins on the day of the month the hospital determines an individual to be eligible for HPE.

Retroactive Medicaid does not have to be authorized at the time of application. It can be requested and added at any point in time. Determining Beginning Date of CHIP Eligibility • 1st of month following month of application eff. 12/01/2016 • If a newborn application is taken within 31 days of birth and approval is authorized within 60 days of application, CHIP eligibility is retroactive to the date of birth.

There is no retroactive eligibility for CHIP eligible children, except newborns.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 953 Effective Month: March 2018 Determining End Dates of Eligibility For Medicaid and CHIP, the end date of eligibility is either: • The last day of the month that eligibility ends, • The death date of the recipient, • The date of entry into a public institution. • HPE ends the last day of the month of the HPE period or the actual day of the month that the full application for Medicaid is denied.

Filling in the Gap for SSI Eligibles Missing months of SSI eligibility may be evaluated with the application for retroactive Medicaid or under a separate application at a future date. SSI payments begin the month following the month of application. The month of application is the E02 month. DOM covers the E02 month automatically since SSI determines the person eligible for the E02 month. Processing Applications & Renewals of DOM Employees & Family Members Medicaid or CHIP cases involving DOM employee family members may not be handled directly or indirectly by the DOM employee with the family relationship. Assigned supervisory staff is responsible for processing affected cases. Ensuring Continuous Eligibility for Children under Age 19 Children determined eligible at the time of application and renewal are locked into a protected period of eligibility for 12-full months. Only a limited number of early termination reasons can interrupt the 12- months of continuous eligibility.

Applies to both MAGI-related children and ABD children Ensuring Eligibility for the 1st Year of Life for the Deemed Eligible Infant An infant born to a Medicaid-eligible mother is eligible from the date of birth through the month the child reaches age one (13 months). Central Office staff inputs deemed eligible infant eligibility upon direct notification by the birthing hospital.

Assigning Review Due Month at Application MAGI – Medicaid application month starts the 12-month count. MAGI – CHIP benefit month starts the 12-month count. MAGI application month (Medicaid) or benefit month (CHIP) + 11 months = review due date.

ABD – month of supervisor authorization starts the 12-month count ABD authorization month + 11 months = review due date.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 954 Effective Month: March 2018 Assigning Review Due Month at Redetermination MAGI and ABD are determined using the time period begin month to start the 12-month count. Begin month of time period + 11 months = review due date.

Administrative Renewal Processing If eligibility can be approved in the same program (Medicaid or CHIP or ABD in the same COE) based on updated data from electronic data sources and reliable case record information then the recipient is notified of the approval and asked to report any changes. Any changes reported are acted on as part of the redetermination process. ABD cases with an asset test are not renewed through this process. Adm. renewals must be initiated before scheduled mailings of pre-populated forms. Processing Renewals Using Pre-populated Review Forms Pre-populated renewal forms are issued by MEDS for MAGI & ABD cases. Due date for return of the signed form MAGI form is 30- days and ABD is 20 days from date form is issued. Returned forms with missing information require the use of a309 for ABD and telephone contact for MAGI. New or additional information requires use of 307 (MAGI) and 307/309 (ABD). Must attempt telephone contact prior to terminating (for MAGI and ABD) to try to secure missing information.

Refer to the Reinstatement policy for compliance after termination. Timely Authorization of a Renewal Review is timely if authorized by the last day of the month in which review is due. If case is closed, action to close must be authorized by the adverse action deadline date.

Reviews are considered overdue if not authorized timely. Adverse Action Deadline(s) for Advance Notice Advance notice (10-days) is required to take an adverse action. The deadline is the 15th day of the current month (exception is February – deadline is the 13th) in order to allow 10-days advance notice plus 5-days mailing time.

Adverse action must be authorized on or before the deadline date to be effective the following month. Advance Notice to Reduce or Terminate Benefits Advance notice is required to: • Terminate eligibility • Convert a case to a reduced services COE (QMB, SLMB, QI) • Terminate a nursing facility per diem payment Advance Notice = 15 full days following the date an adverse action is taken on a case. Medicaid Income increase is the exception.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 955 Effective Month: March 2018 Advance Notice to Increase Medicaid Income Advance notice is 10-days before the date DOM makes its payment to the nursing facility, which is always in the month following the current month. Advance notice is 10 calendar days before the 1st of the following month in order for change to be effective in current month.

Requirement for Ex Parte Reviews Any recipient losing eligibility in one COE must be reviewed under any/all available COE’s using existing information prior to terminating eligibility. If additional information is needed, allow a reasonable opportunity to provide additional information which may include a separate application form (ABD to MAGI & vice versa).

If recipient is being terminated for failure to comply with the renewal process, an ex-parte review is not applicable. SSI Terminations Due to Excess Income or Resources These types of SSI terminations are issued an SSI Redetermination Form for possible eligibility in a Medicaid COE. An abbreviated review form is issued by the system. Continuing eligibility is decided using the completed review form along with data on the SDX and SVES records. If additional information is needed, contact with the individual may be required.

An SSI renewal is a type of ex parte review; however, all factors of eligibility must be verified. Renewal Processing MAGI and ABD renewals may be returned to the RO by any means allowed for submission of an application. Telephone renewals that are not recorded must be sent to the recipient for signature.

Renewals and 12-Months of Continuous Eligibility for Children Children in a case may have different review due dates. Attempt alignment of review dates at the time of renewal if possible but continuous eligibility cannot be shortened (without a written request from the parent/caretaker). A new period of continuous eligibility can be assigned when eligibility is reestablished for all HH members. Children require a full review at the end of their 12- month protected period of eligibility; future end dates are not permitted.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 956 Effective Month: March 2018 Special Reviews due to Reported Changes Reported changes that result in a negative action for adult(s) in the case cannot affect eligibility for children in the case. Reported changes that will not affect eligibility for the household must be acted on, but do not terminate eligibility if a request for information yields no response. Children must be reviewed at the end of their 12-month review period; no future closure dates are permitted.

Reported changes resulting in updated information on all household members can result in a new annual review period for the HH.

Reinstatements Due to Failure to Issue Advance Notice If advance notice was not issued as required to reduce benefits or terminate eligibility, reinstate eligibility for all affected months then issue advance notice to terminate or reduce benefits. Reinstate regardless of whether HH or individual is eligible to remedy failure to issue advance notice.

90-Day Reinstatement Period for MAGI & ABD Compliance within 90-days following effective date of closure to return the signed renewal form and/or provide requested information will result in reinstatement back to the date of closure. If additional information is needed, attempt telephone contact 1st, then use 307 (MAGI/ABD) and 309 (ABD). • If information not provided, no further action required except to close the reinstatement contact & delete time period. • If information provided & eligibility is established, approve reinstatement. • If information provided & ineligibility exists, cancel the reinstatement & set an application contact. Refer to policy for details.

This rule is not applicable for the return of unsigned renewal forms. Corrective Action Requirements If corrective action adversely affects a recipient, handle via completion of an Improper Payment Report. If corrective action favorably affects a recipient, handle as a reinstatement back to the month the error occurred.

There is no time limit imposed for corrective action.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |1 Effective Date: June 2020 Contents 102.01 INTRODUCTION ....................................................................................................... 5 102.01.01 VERIFICATION OF NON-FINANCIAL REQUIREMENTS .................................. 5 102.02 IDENTITY .................................................................................................................. 5 102.03 STATE RESIDENCY ................................................................................................. 6 102.03.01 RESIDENCY REQUIREMENTS ......................................................................... 7 102.03.02 SPECIFIC RESIDENCY PROHIBITIONS ...........................................................7 102.03.03 TEMPORARY ABSENCE FROM THE STATE ................................................... 8 102.03.04 INDIVIDUALS RECEIVING A STATE SUPPLEMENTARY PAYMENT .....................8 102.03.05 INDIVIDUALS RECEIVING A TITLE IV-E PAYMENT ............................................. 8 102.03.06 DETERMINATION OF RESIDENCY (UNDER AGE 21)...................................... 9 102.03.07 DETERMINATION OF RESIDENCY (AGE 21AND OLDER) .................................. 10 102.03.08 STATE PLACEMENT IN AN OUT-OF-STATE INSTITUTION ........................... 11 102.03.09 OUT-OF-STATE PLACEMENTS ...................................................................... 12 102.03.10 RESIDENCY ISSUES ................................................................................... 12 102.03.11 OUT-OF-STATE RECIPIENT MOVING TO MS ................................................ 13 102.03.12 MS RECIPIENT MOVING TO ANOTHER STATE ............................................. 15 102.03.13 MIGRANT/SEASONAL FARM WORKERS ....................................................... 16 102.03.14 HOMELESS INDIVIDUALS............................................................................... 17 102.03.15 VERIFICATION OF STATE RESIDENCY ......................................................... 17 102.03.16 PARIS MATCH DATA – DUPLICATE PARTICIPATION ........................................ 17 102.04 UNITED STATES CITIZENSHIP .................................................................................... 19 102.04.01 EXEMPTIONS FROM CITIZENSHIP/IDENTITY REQUIREMENTS ...................... 20 102.04.02 VERIFICATION OF U.S. CITIZENSHIP AND IDENTITY USING ELECTRONIC DATA SOURCES .................................................................................................................. 21

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |2 Effective Date: June 2020 102.04.03 VERIFICATION OF U.S. CITIZENSHIP AND IDENTITY UNDER THE CHILD CITIZENSHIP ACT OF 2000 ................................................................................................. 23 102.04.04 VERIFICATION OF U.S. CITIZENSHIP AND IDENTITY USING OTHER REQUIRED DOCUMENTS .................................................................................................... 23 102.04.05 90-DAY REASONABLE OPPORTUNITY PERIOD ................................................ 25 102.04.06 EVIDENCE OF U. S. CITIZENSHIP ...................................................................... 28 102.04.07 EVIDENCE OF IDENTITY .................................................................................... 36 102.05 ALIEN STATUS .................................................................................................. 37 102.05.01 CLASSIFICATIONS OF QUALIFIED ALIENS ................................................... 37 102.05.02 GRANDFATHERED ALIENS ............................................................................ 39 102.05.03 ALIEN CLASSES SUBJECT TO A 5-YEAR DISQUALIFICATION PERIOD .......... 40 102.05.04 ALIEN CLASSES SUBJECT TO A 7-YEAR LIMIT ON ELIGIBILITY ..................... 40 102.05.05 ALIENS EXEMPT FROM THE 5-YEAR DISQUALIFICATION AND THE 7-YEAR LIMIT .............................................................................................................................................. 41 102.05.06 REQUIREMENT FOR 40 QUALIFYING QUARTERS ............................................ 42 102.05.06A 40 QUALIFYING QUARTERS OF EARNINGS .................................................... 43 102.05.06B PROCEDURES TO VERIFY 40 QUALIFYING QUARTERS .......................... 43 102.05.07 ENUMERATION EXCEPTION FOR QUALIFIED ALIENS ................................... 44 102.05.08 ELECTRONIC VERIFICATION OF ALIEN STATUS.............................................. 45 102.05.08A PROCEDURES FOR OBTAINING ELECTRONIC VERIFICATION FOR ALIENS .............................................................................................................................. 45 102.05.08B VERIFICATION PROCEDURES FOR GRANDFATHERED ALIENS ............... 47 102.05.08C VERIFICATION PROCEDURES FOR VICTIMS OF TRAFFICKING .............................. 48 102.05.08D VERIFICATION PROCEDURES FOR BATTERED ALIENS ......................................... 48 102.05.08E VETERANS, ACTIVE-DUTY MILITARY AND FAMILY MEMBER REQUIREMENTS................49

102.05.09 NON-QUALIFIED ALIENS ................................................................................. 50 102.05.10 EMERGENCY MEDICAL SERVICES PROCESS ............................................. 52 102.05.11 BUDGETING FOR CITIZEN CHILDREN OF NON-QUALIFIED ALIEN(S) ........ 54

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |3 Effective Date: June 2020 102.05.12 PUBLIC CHARGE ............................................................................................ 54 102.05.13 ALIEN STATUS CHART ...................................................................................... 55 102.06 SOCIAL SECURITY NUMBER (SSN) ........................................................................... 63 102.06.01 EXCEPTIONS TO THE ENUMERATION REQUIREMENT FOR APPLICANTS .................... 64 102.06.02 NON-APPLICANTS AND ENUMERATION ................................................................. 64 102.06.03 USE OF SSN’s ................................................................................................................. .....64 102.06.04 APPLICATION FOR A SOCIAL SECURITY NUMBER ................................................ 65 102.06.05 VERIFICATION OF THE SSN ............................................................................. 66 102.07 CATEGORICAL ELIGIBILITY ........................................................................................ 67 102.08 GENERAL ELIGIBILITY REQUIREMENTS ............................................................. 70 102.08.01 VERIFICATION OF AGE .................................................................................... 71 102.08.02 MARITAL RELATIONSHIPS ............................................................................. 73 102.08.03 DEFINITION OF A CHILD ..................................................................................... 78 102.08.04 UTILZATION OF OTHER BENEFITS –GENERAL ........................................... 82 102.08.05 ASSIGNMENT OF THIRD-PARTY RIGHTS – GENERAL ................................ 86 102.08.05 A CHIP AND OTHER INSURANCE COVERAGE ............................................... 88 102.08.06 CHILD SUPPORT REQUIRMENTS - GENERAL .............................................. 90 102.08.06 A CHILD SUPPORT REQUIREMENTS – ABD PROGRAMS ........................... 91 102.08.06B CHILD SUPPORT REQUIREMENTS – MAGI PROGRAMS .......................... 91 102.09 ABD DISABILITY AND BLINDNESS DETERMINATIONS ............................................. 94 102.09.01 DEFINITIONS ....................................................................................................... 94 102.09.02 DISABILITY DETERMINATION PROCESS FOR SSI APPLICANTS ................ 95 102.09.03 EXCEPTIONS TO OBTAINING DDS DISABILITY APPROVALS ..................... 97 102.09.04 OBTAINING DDS DISABILITY DECISIONS .......................................................... 99 102.09.05 TEMPORARY SSI CLOSURES ...................................................................... 102 102.10 ESTATE RECOVERY REQUIREMENTS .............................................................. 103 102.11 MAGI NON-FINANCIAL REQUIREMENTS ................................................................. 105 102.11.01 DEPRIVATION ............................................................................................... 105

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |4 Effective Date: June 2020 102.11.02 TEMPORARY ABSENCE FROM THE HOME ................................................ 108 102.11.03 RELATIONSHIP ............................................................................................. 109 102.11.03 A MAGI FPL PROGRAMS .............................................................................. 109 102.11.03 B PARENT/CARETAKER PROGRAM (COE-075) .......................................... 109 102.12 PUBLIC INSTITUTIONS ........................................................................................ 111 102.12.01 INSTITUTIONS ........................................................................................... 111 102.12.02 INMATE STATUS .......................................................................................... 112 102.12.03 INMATE ELIGIBILITY FOR MEDICAID .......................................................... 113 102.12.04 INSTITUTIONS FOR MENTAL DISEASES (IMD’S) ............................................ 117 102.13 MEDICAID/MEDICARE REQUIREMENTS AND COORDINATION ............................. 119 102.13.01 MEDICARE ENTITLEMENT – BASIC INFORMATION ........................................ 120 102.13.02 MEDICAID PAYMENT OF MEDICARE PART A AND PART B COST-SHARING EXPENSES ......................................................................................................................... 122 102.13.03 WHO SHOULD APPLY & ACCEPT MEDICARE (IN ALL COE’S) ......................... 123 102.13.04 DUAL ELIGIBILITY AND THE BUY-IN EFFECTIVE DATE .................................. 127 102.13.05 DUAL ELIGIBILITY, THE LOW-INCOME SUBSIDY (LIS) AND MEDICARE PART D PHARMACY PLANS ........................................................................................................ 130 102.13.06 SSA OUTREACH TO LOW-INCOME MEDICARE BENEFICIARIES ................... 132 102.13.07 MEDICARE PART C – MEDICARE ADVANTAGE PLANS.................................. 133 102.14 NON-FINANCIAL VERIFICATION SUMMARY CHART ............................................... 134

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |5 Effective Date: January 2019

102.01 INTRODUCTION This chapter discusses non-financial criteria which must be met for an individual to qualify in the Aged, Blind and Disabled (ABD) or MAGI-related programs and the acceptable methods and procedures which are used to establish eligibility. In each section, policy or procedures which are specific to one program, or the other are discussed separately under a heading for that program; otherwise, the provision applies to both program areas. 102.01.01 VERIFICATION OF NON-FINANCIAL REQUIREMENTS Verification other than self-declaration is required to document certain non-financial factors such as citizenship, alien status or proof of enumeration when a Social Security Number has not been assigned. However, for those eligibility factors which may be verified by self-declaration or client statement, no additional verification is necessary unless information provided by self-declaration is confusing or contradictory to other information available to the regional office and documented in the record. Information is considered questionable and subject to additional verification when: • There are inconsistencies in the applicant/recipient’s oral or written statements • There are inconsistencies between the applicant/recipient’s allegations and information from electronic data sources or other documents or prior records. • The applicant/recipient or his representative is unsure of the accuracy of his own statements.

102.02 IDENTITY The identity of all applicants must be verified. The identity of applicants is usually verified at the same time U.S. Citizenship or qualified alien status is verified, as outlined in 102.04, U.S. Citizenship or 102.05, Alien Status. If identity cannot be verified using the same method as verifying citizenship or alien status, the acceptable method of verifying identity apart from citizenship or alien status is addressed in sections 102.04 and 102.05.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |6 Effective Date: January 2019

Identity Verification for Non-Applicants If the responsible person is a non-applicant parent, relative, non-relative or an authorized representative filing the application on behalf of others, the identity of the non-applicant must be verified by either (1) picture identification, or (2) two different forms of non-picture identification, including such documents as EBT, WIC or other benefit cards or notices, credit or bank cards, employment badges, check stubs or other wage verification, insurance cards, etc., or (3) personal knowledge of a Medicaid staff member. Non-applicants must not be asked to provide any document which discloses their own citizenship, or immigration status however, such documents may be provided voluntarily.

Good Cause Determination for Non-Applicants If the regional office determines a non-applicant head of household or authorized representative cannot meet the identity verification requirement, the regional bureau director will review case circumstances and make a good cause determination. If good cause exists, the director can decide to (1) accept one form of non-picture ID when the individual can present only one or (2) waive the requirement altogether. An applicant’s eligibility cannot be adversely affected when a non-applicant is unable or refuses to verify their own identity.

One-Time Verification Requirement Documentation of identity is a one-time requirement unless there is a valid reason to question the accuracy of the initial determination. Return all original documents used to verify identity immediately to the individual if viewing the document in-person; otherwise, return original documents by mail within two working days.

102.03 STATE RESIDENCY Medicaid must be available to eligible residents of the state. A resident is someone who voluntarily lives in Mississippi with the intention to remain permanently or for an indefinite period of time, or someone living in Mississippi, having entered with a job commitment or for the purpose of seeking employment, whether or not the individual is currently employed.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |7 Effective Date: January 2019

102.03.01 RESIDENCY REQUIREMENTS

The individual must live in Mississippi and meet all other eligibility requirements in order to receive Medicaid benefits. A spouse and children living in the same household with the individual are also considered MS residents.

No Permanent MS Address An individual, including someone with no permanent address, is a resident of MS if he lives in the state and is capable of stating and does state intent to remain here permanently or for an indefinite period of time. Indefinite indicates the individual does not have a date in mind when he will no longer be a resident of the state.

Residing in Another State An individual who claims to be a resident of MS, but is residing in another state, must show an established address or place of residence in MS before he can be considered temporarily absent from MS for Medicaid purposes.

Stating Intent to Reside A person is considered capable of stating intent to reside unless he has an IQ of 49 or less or has a mental age of seven or less based on tests acceptable to the Department of Mental Health; or is judged legally incompetent; or is found incapable of indicating intent based on medical documentation obtained from a physician, psychologist or other individual licensed by the state in the field of intellectual disability.

102.03.02 SPECIFIC RESIDENCY PROHIBITIONS

An individual cannot be denied Medicaid based on residency for the following reasons: • The individual has not resided in MS for a specified period of time. There is no durational requirement for residency. • The individual is temporarily absent from MS and intends to return when the purpose of the absence has been accomplished. However, if another state has accepted him as a resident for Medicaid purposes, the individual cannot be considered a MS resident.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |8 102.03.03 TEMPORARY ABSENCE FROM THE STATE The recipient is responsible for reporting a temporary absence from Mississippi and for giving information on his purpose, plans and dates of departure and return. The recipient’s eligibility must be reviewed every three (3) months to determine the recipient’s continued intent to reside in MS. No limit is place on the length of the out-of-state visit.; however, if it is determined that an individual has left the state with no declared intention to return, the individual will be deemed to have given up MS residency and his eligibility will be terminated. Refer to 102.03.10 for further discussion. 102.03.04 INDIVIDUALS RECEIVING A STATE SUPPLEMENTARY PAYMENT An individual receiving a state supplementary payment (optional or mandatory), such as payment from a state to supplement SSI, state adoption assistance or state foster care payment, is a resident of the state making the supplementary payment. However, if the state making the payment is a member of the Interstate Compact on Adoption and Medical Assistance (ICAMA) and an agreement is in effect, the child is a resident of the state in which he is living. Mississippi is a member of ICAMA; however, Medicaid eligibility through the Mississippi Department of Child Protection Services (DCPS) is not automatic. The placing state must coordinate with DCPS to authorize Medicaid eligibility through an ICAMA agreement for the child to be covered through DCPS. If the family files an application for the child with the regional office, supplementary payments made by another state must be counted as income. In addition, parental income must be included along with the income of any siblings included in the application, if applicable. 102.03.05 INDIVIDUALS RECEIVING A TITLE IV-E PAYMENT An individual, who is receiving a Title IV-E foster care or adoption assistance payment, is a resident of the state in which the child is currently residing. When a child receiving a Title IV-E payment moves to MS from another state, Medicaid eligibility is possible through the Mississippi Department of Child Protection Services Effective Date: July 2025

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |9 Effective Date: January 2019 (DCPS); however, it is not automatic. The placing state must coordinate with DCPS for Medicaid eligibility through the foster care or adoption assistance programs to be authorized by DCPS. If the family files an application for the child with the regional office, parental income must be included along with the income of any siblings included in the application, if applicable. Title IV-E foster care and adoption assistance payments are federal payments which are disregarded income in determining Medicaid and CHIP eligibility. 102.03.06 DETERMINATION OF RESIDENCY (UNDER AGE 21) Use the instructions in this section to determine residency for persons under age 21: Not in an Institution or Under Parental Care and Control If a non-institutionalized individual under age 21 is emancipated from his/her parents or is married and capable of stating intent, the state of residence is where the individual is living with the intent to remain permanently or for an indefinite period. Blind or Disabled Not in an Institution An individual, under age 21 and in a private living arrangement, whose eligibility is based on blindness or disability, is a resident of the state where the individual is actually living. Others Under 21 Not Living in an Institution Effective 01/01/2014, the state of residence is: • The state where the individual resides with or without a fixed address, or • The state of residency of the parent, caretaker or guardian with whom the individual resides. Prior to 01/01/2014, the state in which the parent(s) resided was the state of residence if the individual was still considered a minor. Under 21, In an Institution and Under Parental Care and Control The state of residence is: • The parent's state of residence at the time of placement; however, if a legal guardian has been appointed and parental rights have been terminated, the state of residence of the legal guardian is used instead of the parents; or. • The current state of residence of the parent who files the application, if the

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |10 Effective Date: January 2019 individual is residing in an institution in that state. However, if a legal guardian has been appointed and parental rights have been terminated, the state of residence of the guardian is used instead of the parents; or • The state of residence of the individual or party that files an application if the individual: (1) Has been abandoned by his parent(s), (2) Does not have a legal guardian and (3) Is residing in an institution in that state. 102.03.07 DETERMINATION OF RESIDENCY (AGE 21AND OLDER) Use the instructions in this section to determine residency for individuals ages 21 and older. Not in an Institution The state of residence is where the individual is living with the intent to remain there permanently or for an indefinite period, or the state where the individual is living because the individual had a job commitment or is seeking employment, either currently employed or not. If the individual is incapable of stating intent, the state of residence is where the individual is living. In an Institution and Became Incapable of Stating Intent before Age 21 The state of residence is: • The state of residence of the parent who is applying for Medicaid on the individual's behalf. If a legal guardian has been appointed and parental rights have been terminated, the state of residence of the legal guardian is used instead of the parent. • The state of residence of the parent at the time of placement. If a legal guardian has been appointed and parental rights have been terminated, the state of residence of the guardian is used instead of the parents. • The current state of residence of the parent or legal guardian who files the application, if the individual is residing in an institution in that state. If a legal guardian has been appointed and parental rights have been terminated, the state of residence of the guardian is used instead of the parents.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |11 Effective Date: January 2019 • The state of residence of the individual or party that files an application if the individual: (1) has been abandoned by his parent(s), (2) does not have a legal guardian and (3) is residing in an institution in that state. In an Institution and Became Incapable of Stating Intent at or After 21 The state of residence is where the individual is physically present, except in instances where another state made the placement. Any Other Individual in an Institution The state of residence is where the individual is living permanently or for an indefinite period of time. NOTE: When a competent individual leaves the facility in which he was placed, his residence becomes the state where he is physically located. 102.03.08 STATE PLACEMENT IN AN OUT-OF-STATE INSTITUTION If a state agency arranges for an individual to be placed in an institution in another state, the state arranging or making the placement is the individual's state of residence. For purposes of state placement, the term “institution” also includes licensed foster care homes that provide food, shelter, and supportive services for one or more individuals unrelated to the proprietor. The following actions are not considered state placement: • Providing basic information to individuals about another state's Medicaid program and information about healthcare services and facilities in another state or • Providing information regarding institutions in another state if the individual is capable of indicating intent and decides to move.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |12 102.03.09 OUT-OF-STATE PLACEMENTS There are three circumstances under which Mississippi will pay for placement in an out-of-state nursing facility. (1) If the agency has a part in the placement or otherwise approves or authorizes an out-of-state placement, regional offices will be notified on an individual case basis. (2) When a MS resident moves to a nursing facility in another state, only the partial month of the move can be paid if the facility enrolls as a MS provider. The individual is considered a resident of the new state effective with the first full month of residence and has to qualify for Medicaid eligibility and per diem payment in the new state. (3) A provider supplying a service not available in Mississippi to a Mississippi Medicaid beneficiary who has retained Mississippi residency may file a claim for payment. If an individual moves to Mississippi, he would apply for benefits here and meet all eligibility requirements. If he is transferred directly from one medical facility to another, the time spent in the out-of-state facility can be used to meet the 30 consecutive day requirement. 102.03.10 RESIDENCY ISSUES Termination of Benefits in the Former State of Residence An individual coming to MS from another state may be considered a resident of MS in the month of the move, provided the individual intends to reside in MS. However, individuals are not entitled to duplication of Medicaid services from both the former state and Mississippi. When a Medicaid recipient moves from one state to another, the former state initiates the change effective the first month in which it can administratively terminate the case in accordance with timely and adequate notice regulations. Request for MS Medicaid Prior to Termination in Former State There will be occasions when a recipient requests that eligibility in Mississippi begin prior to the effective date of closure in the former state. Neither state can deny coverage because of administrative requirements or time constraints needed to take Effective Date: July 2025

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |13 Effective Date: January 2019 action to terminate benefits in the former state. However, when an individual is no longer a resident of a state, that state is not required to pay for any services incurred in Mississippi. If the former state will pay out of state claims, Mississippi cannot approve eligibility until the former state has terminated services. If the former state will not pay out of state claims, duplication of services is not an issue and Medicaid eligibility in Mississippi can potentially begin with the month of the move. 102.03.11 OUT-OF-STATE RECIPIENT MOVING TO MS If an applicant who was receiving Medicaid in another state before moving to MS does not have verification of termination of benefits in the other state, the Medicaid Specialist is responsible for contacting the previous state to: • Notify the state of the individual’s move to MS. • Request that eligibility in the other state be terminated so eligibility for MS Medicaid can be determined. • The Medicaid Specialist will include any letters/documents or telephone contact information with the out-of-state agency in the case record to verify the eligibility status of the applicant. MS Coverage Requested Prior to Effective Date of Closure in Other State When the individual requests coverage in MS prior to the effective date of closure in the former state, the Medicaid Specialist must determine if the other state will pay out of state claims. If the former state will not pay out-of-state claims, MS Medicaid benefits can be authorized beginning with the month of the move, if the applicant is otherwise eligible. If the former state will pay out of state claims, MS Medicaid will not be authorized even if a MS provider refuses to file the client’s claims with the other state. If the former state will pay for partial months or any subsequent months for nursing home recipients, eligibility for MS Medicaid cannot begin until the former state specifies their payment(s) will stop. The case narrative must be documented to support the action taken.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |14 Effective Date: July 2025 NOTE: When two or more states cannot agree on residence, the state where the individual is physically located is his residence. Coordination efforts should ensure that an eligible person does not experience a discontinuation of benefits. 102.03.12 MS RECIPIENT MOVING TO ANOTHER STATE A Mississippi recipient who moves to another state with the intent to remain is no longer eligible to receive benefits from MS. Changes in residency may be received from the recipient, head of household, authorized representative, out-of-state agencies, post office, providers and other community sources. The type of action needed in response to the report depends in large part upon the source of the information. Follow the procedures below to take action on the change. Procedures When a Mississippi Recipient has Moved from the State • Change Reported by Recipient or Representative When the loss of residency is reported by the recipient, the head of household, responsible adult or authorized representative, the information is verified. • Change Reported by Out of State Agency When an out-of-state agency reports a MS recipient has applied for benefits in that state, loss of MS residency is verified. • Taking Action on Verified Change The specialist will document the contact and obtain the new address. When multiple family members are involved, the specialist must determine whether all members have left the state. Action will be taken to terminate the eligibility of the recipients who are no longer state residents. o The closure notice will be sent to the primary person for the case at the appropriate address. o A child who remains in MS has continuous eligibility and will not be terminated when he moves from one household to another within the state. o If an adult recipient continues to reside in MS, a review may be needed to determine the adult’s continued eligibility apart from the non-resident spouse and/or children.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |15 Effective Date: July 2025 • Unverified Change Reported by Other Sources When loss of residency is reported by other sources, the specialist must first verify the accuracy of the information prior to taking action on the case: o The worker must make at least 2 attempts using at least 2 methods (such as mail, phone, and email) and allow the client at least 30 days to respond. o Attempt a telephone contact using the telephone number in the case record to verify the information received. o If no telephone is on file but an email address is on file, attempt to email the client. o If the client has no phone and no email, document this in the case narrative as why two methods of contact couldn’t be attempted. o If telephone and email contact cannot be made, send a 307 giving 30 days to respond to the address on file in the record and to the out-of-state address, if one is known. o If it is subsequently verified some or all recipients have moved from the state, take action to terminate eligibility for the appropriate individuals and send the termination notice to the primary person for the case at the appropriate address.  A child who remains in MS has continuous eligibility and will not be terminated when he moves from one household to another within the state.  If an adult recipient continues to reside in MS, a review may be needed to determine the adult’s continued eligibility apart from the non-resident spouse and/or children o If there is no response to the 307 and the information cannot be verified or reasonable attempts to locate the household have failed, take action to close the case.  The closure notice should be sent to the primary person for the case at the in-state address and the out-of-state address, if one is known.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |16 Effective Date: July 2025 102.03.13 MIGRANT/SEASONAL FARM WORKERS An individual involved in work of a transient nature or someone who goes to another state seeking employment as a migrant or seasonal worker can choose too either: • Establish residence in the state where he is employed or seeking employment, or • Claim one state as his domicile or state of residence. 102.03.14 HOMELESS INDIVIDUALS If otherwise eligible, a person who is homeless or who frequently moves from one address to another can qualify for Medicaid. Medicaid cards must be available to individuals with no fixed home or mailing address. Medicaid cards for homeless individuals can be mailed to a specific shelter, facility or the Regional Medicaid Office based upon the mutual agreement of the parties. The recipient should be advised of the time and place the card will be available. 102.03.15 VERIFICATION OF STATE RESIDENCY State residency is generally verified by self-declaration. If the self-declaration is questionable or electronic data sources, such as PARIS computer matching, indicate an out of state residence, documents such as those listed below can If be used to verify residency (Refer to 102.01.01): • Current MS driver’s license or state ID card, • Tax receipt for a car tag or other real property owned in MS with a current MS address, • Mortgage or rent receipts, • Utility bills, • Employer statement, • Notice of closure of Medicaid from the previous state of residence. NOTE: When a Mississippi residency address is reported with an out of state mailing address, obtain a reasonable explanation and document the case. If a reasonable explanation is not provided, request documentary verification of Mississippi residency. 102.03.16 PARIS MATCH DATA – DUPLICATE PARTICIPATION

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |17 Effective Date: January 2019 PARIS (Public Assistance Reporting Information System) matches are performed quarterly using the eligibility file of active recipients in Mississippi with the eligibility files from all other states for the purpose of detecting duplicate participation. Any match data whereby a MS recipient’s SSN has been matched with the SSN of a recipient in another state will appear as an alert that must be reviewed for possible action. If the data is already known or is being processed, document the case narrative accordingly. If the data is not known, follow-up is required to notify the recipient of the data match and request independent verification of state residency, as outlined above in 102.03.12 and 102.03.15. Verification must be provided to establish MS residency. 102.04 UNITED STATES CITIZENSHIP An eligible individual for ABD Medicaid or MAGI-related Medicaid or CHIP must either be a citizen of the United States or a qualified alien, discussed in Section 102.05. Most United States citizens are natural-born citizens, meaning they were born in the United States or were born to United States citizens overseas. Individuals born in the United States, which includes the 50 states, the District of Columbia, Puerto Rico, Guam, the U. S. Virgin Islands, the Northern Marinara Islands and the Panama Canal Zone before it was returned to Panama, are U. S. citizens at birth (unless born to foreign diplomatic staff), regardless of the citizenship or nationality of the parents. Nationals from American Samoa or Swain’s Island are citizens for Medicaid purposes. Verification of U.S. citizenship and qualified non-citizen status is a statutory requirement under The Deficit Reduction Act (DRA) of 2005 and statutes collectively called the Affordable Care Act. Certain applicants and recipients are exempt from providing verification of citizenship or identity as specified in 102.04.01 below. Others are exempt from providing documentation of citizenship or identity because electronic data from the Federal Data Services Hub and/or SVES provides proof of citizenship/identity. However, for others, verification is required. Verification must be either an original document or copy certified by the issuing agency or document(s) can be a photocopy, facsimile, scanned or other copy of the original or certified document. If information on a copy is inconsistent with other available information or there is reason to question the validity of, or the information in, a copy, request the original or certified copy of the document.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |18 Effective Date: July 2025 Return original and certified copies to the individual immediately. Original documents and certified copies received in the mail or at out-stationed sites (unless copying is allowed), must be mailed back to the individual within two working days. Extreme care must be taken to ensure these important personal documents are not lost, misplaced or misrouted. Return photocopied documents submitted if requested by the individual. One-Time Verification Requirement Documentation of citizenship is generally a one-time requirement. The individual is not required to provide verification again unless (1) there is a valid reason to question the accuracy of the initial determination or (2) a reapplication is filed after the record retention period and the case has been destroyed. 102.04.01 EXEMPTIONS FROM CITIZENSHIP/IDENTITY REQUIREMENTS Individuals declaring to be U. S. citizens are exempt from citizenship and identity documentation requirements if they are in one of the following categories: • Medicare recipients entitled to, or enrolled in, Medicare Part A or B under any claim number are exempt from the verification requirements. If SVES does not confirm Medicare entitlement, then a copy of the Medicare card should be requested and retained in the case record. However, if the individual cannot provide the Medicare card, agency verification of enrollment in Medicare may be used, if it is available. • Individuals receiving Social Security benefits under “A” claim number based on their own disability are exempt from the verification requirements. The individual must be a current recipient of Social Security Disability. Prior receipt of disability does not qualify an individual for this exemption. In addition, this exemption does not apply to individuals receiving early retirement or to dependents drawing off of the disabled individual’s record. • Individuals receiving SSI benefits are exempt. The individual must be a current SSI recipient. Prior receipt of SSI does not qualify a person for this exemption. Former SSI recipients applying for Medicaid must provide evidence of citizenship and identity. However, current SSI recipients applying only for retroactive coverage are exempt.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |19 Effective Date: January 2019 • Children in receipt of Title IV-B services or Title IV-E Adoption Assistance or foster care payments are exempt. Medicaid eligibility determinations for children in this category are made by the Department of Child Protection Services. • Deemed eligible children are exempt from citizenship and identity verification requirements until the end of the deemed year. All eligibility factors, including documentation of citizenship and identity, must be met for eligibility to continue beyond the first year. 102.04.02 VERIFICATION OF U.S. CITIZENSHIP AND IDENTITY USING ELECTRONIC DATA SOURCES Effective for applications received after May 1, 2010, the Children’s Health Insurance Reauthorization Act of 2009 allowed states to use SVES (State Verification and Exchange System) data from the Social Security Administration (SSA) to establish citizenship and identity for Medicaid and CHIP purposes under the condition that the SVES response is able to substantiate citizenship. Effective January 1, 2014, the ACA required state access to SSA data for applicants from the Federal Data Services Hub (FDSH), referred to as SSA Composite data. MEDS displays both FDSH and SVES data and citizenship verification is potentially available from either source. FDSH SSA Composite data and/or SVES data is a primary verification source which must be used before requiring an applicant to produce documentary evidence. All registered applications in MEDS will include a request for SSA to verify citizenship. A manual SVES request will only result in a citizenship response if the initial SSA query was a non-match with SSA records, such as a name/SSN mismatch. Verification of citizenship and identity using FDSH or SVES data is a one-time occurrence at application and once a citizenship response has been received, another citizenship request cannot be submitted for the same individual.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |20 Effective Date: January 2019 SSA Citizenship Response The FDSH SSA Composite response to citizenship is a Yes (Y) or No (N) response. The possible SVES citizenship responses from SSA are as follows: Code Response Decision A SSN is verified, no indication of death Citizenship is substantiated B SSN is verified, no indication of death Unable to substantiate citizenship C SSN is verified, indication of death Citizenship is substantiated D SSN is verified, indication of death Unable to substantiate citizenship When the SVES response is a non-match, a manual SVES request must be submitted with the correct information (check name, SSN and DOB to identify the mismatch). Taking Action on SSA Response A “Y” response appearing as SSA Composite data or a response of “A” or “C” in the SVES response for an applicant verifies citizenship and identity for eligibility purposes. If SSA indicates the individual is deceased but the regional office is unaware of this, the discrepancy must be resolved. A response of “N” appearing as SSA Composite data or a response of “B” or “D” in the SVES response indicates citizenship and identity is not verified and further action is necessary: • If the applicant is not otherwise eligible, deny the application for the appropriate reason. In the comment section of the notice, inform the applicant that verification of citizenship and identity will be required if a reapplication is filed. • If the applicant is a former recipient and the case record contains documentary verification of citizenship/identity as outlined in 102.04.04 or if the individual is exempt from the citizenship verification requirements as outlined in 102.04.01 above, proceed with the eligibility determination. If SSA indicates the individual is deceased and the regional office is unaware of this, the discrepancy must be resolved.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |21 Effective Date: January 2019 • If the SVES response does not substantiate citizenship/identity but the applicant is otherwise eligible, the 90-day reasonable opportunity period applies as outlined in 102.04.05 below. Applicants must be allowed time to provide the needed citizenship and identity information and eligibility is allowed during this time period if citizenship/identity is the only factor of eligibility at issue. NOTE: If SSA data fails to confirm citizenship for an individual alleging birth in the U.S., verify citizenship using EVVE (Electronic Verification of Vital Events) if the individual was born in a state participating in EVVE. If U.S. citizenship can be verified using EVVE, verify identity for the applicant using acceptable proof of identity as specified in 102.04.07, Evidence of Identity. 102.04.03 VERIFICATION OF U.S. CITIZENSHIP AND IDENTITY UNDER THE CHILD CITIZENSHIP ACT OF 2000 The Child Citizenship Act (CCA) of 2000, enacted February 21, 2001, amended the Immigration and Naturalization Act to provide automatic acquisition of U. S. citizenship by operation of law to certain foreign-born children, including orphans with a full and final adoption by U. S. citizens, either abroad or in the U. S., and the biological or legitimated children of U. S. citizens. Under the CCA, “automatic” means the child automatically acquires U.S. citizenship on the date the child meets all of the requirements of the law, without additional action. Prior to the implementation of this act, these children had to go through the naturalization process to become citizens. Procedures to Verify Citizenship under the Child Citizenship Act of 2000 The child will automatically acquire U. S. citizenship on the date that all of the following requirements are met: (1) The child has at least one natural or adoptive parent who is a U. S. citizen by birth or naturalization; and (2) The child is under 18 years of age; and (3) The child is currently permanently residing in the United States in the legal and physical custody of citizen parents; and (4) The child is a lawful permanent resident or acquires this status; and (5) If adopted, child meets the requirements applicable to adopted children under immigration law.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |22 Effective Date: January 2019 In general, to verify the citizenship status of foreign-born children, use the “Evidence of U.S. Citizenship” described in 102.04.06 below if the citizenship of child cannot be verified using SSA data. 102.04.04 VERIFICATION OF U.S. CITIZENSHIP AND IDENTITY USING OTHER REQUIRED DOCUMENTS The verification requirements found in this section pertain only to applicants declaring to be U. S. citizens. Aliens applying for Emergency Medicaid services only are not required to provide information about citizenship, immigration status or Social Security Number and should not be asked to do so. Refer to Section 102.05 for handling applicants who are qualified or non-qualified aliens. The process of obtaining primary, secondary and third and fourth level documents, as outlined below, is only for applicants who are not exempt from the requirements as outlined in 102.04.01, or whose citizenship/identity cannot be verified using electronic data as discussed in 102.04.02 or whose citizenship is not verified using the Child Citizenship Act process described in 102.04.03. For all applicants who are eligible on all factors other than providing verification of citizenship and identity verification documents as described below, the 90-Day Reasonable Opportunity period applies as outlined in 102.04.05 below. Hierarchy of Evidence The evidences of citizenship are divided into a hierarchy of primary, secondary, third level and fourth level documents. Primary evidence has the highest reliability and conclusively establishes both a person’s citizenship and identity. When the individual has secondary, third or fourth level documentation of citizenship, additional verification must be provided to establish identity. The evidences of identity are not prioritized. Available Documents The highest level of verification must be used if it is available. “Available” means the document exists and can be obtained within the time period allowed for providing information during application processing or during the reasonable opportunity period. Therefore, when a higher-level document is not available, it is permissible to use a lower-level document. For example, a U. S. Passport is primary evidence of citizenship and identity. If the

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |23 individual possesses a passport, it must be provided. However, if the individual does not already have a passport, the document is generally considered unavailable due to the time required to process a passport application so the individual can meet verification requirements by providing a lower-level document, such as a birth certificate, secondary evidence of citizenship, and a driver’s license or other picture identification to verify identity. Economic Hardship It is generally the individual’s responsibility to provide required documents and pay associated fees to obtain them. However, when individuals are economically disadvantaged and unable to pay fees associated with obtaining necessary documents, lower level evidence of citizenship and identity will be accepted. Providing Assistance When an applicant or beneficiary, who is homeless, an amnesia victim, mentally impaired or physically incapacitated and lacks someone to act for them, does not have the required verifications, the Medicaid Specialist must assist the individual to document U.S. citizenship and/or identity. In addition, staff must attempt to contact and provide assistance to any applicant or recipient who is known to be deaf, hard of hearing, blind, mentally or visually impaired, physically incapacitated or otherwise disabled, illiterate, limited English proficient, homeless and/or requires communication assistance with reading agency notices and other written correspondence prior to denying or terminating their case. The case record must be documented with all efforts taken by specialists to provide assistance to individuals with special needs, conditions and/or barriers. Eligibility will not be denied or terminated until all avenues of verification have been exhausted. However, when the individual has been given a reasonable opportunity to provide the information and all avenues of assistance have been exhausted and documented by the specialist, eligibility must be denied or terminated if needed information is not provided. 102.04.05 90-DAY REASONABLE OPPORTUNITY PERIOD The 90-day reasonable opportunity period is applicable to those declaring to be U.S. citizens and to those declaring to be qualified aliens, as outlined in Section 102.05. As indicated, verifications(s) are needed when there is an inconsistency between the Effective Date: July 2025

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |24 Effective Date: July 2025 data available from an electronic data source and the individual’s declaration of citizenship or immigration status that must be resolved. NOTE: If an applicant does not declare to be a citizen or to be in a qualified immigration status, the reasonable opportunity period does not apply. Reasonable Opportunity Process • The reasonable opportunity period applies when all other information necessary to establish eligibility is available and the individual is otherwise eligible. If an applicant is ineligible on any other factor of eligibility, such as excess income or disability not established, the application should be denied for the reason other than citizenship/alien status. • If the applicant declaring to be a citizen or qualified alien is otherwise eligible pending a determination of U.S. citizenship or qualified alien status, Medicaid or CHIP benefits may not be delayed or denied. • The otherwise eligible applicant will be enrolled while the process to verify citizenship or qualified alien status continues. This provision includes delays experienced by the applicant in obtaining documents and/or in the SAVE process when a response is not returned immediately, additional documentation is requested, or documents must be submitted to Homeland Security. The Reasonable Opportunity Period is implemented in the system as follows: 1. Medicaid benefits provided during the reasonable opportunity period begin the first day of application month (or the month after application for CHIP) and run 90 days plus 5 days mailing time from the date of the approval notice. The 95-day period does not include approval for any retroactive month(s). If eligible, retro eligibility is authorized after citizenship/identity is verified. 2. MEDS provides for an approval by selecting the “90-Day Reasonable Opportunity Period” selection in the drop-down box for citizenship verification. An approval notice will be issued with language explaining the approval is temporary pending further verification. o The worker must issue a 307, Request for Information, at the same time the approval notice is issued informing the applicant of the information needed to establish citizenship and/or identity or qualified alien status with a due date that is 90 days plus 5 days mailing from the date of the approval notice. A worker alert must be set for follow-up. The 90-Day Reasonable Opportunity Aging

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |25 Effective Date: July 2025 Report (RJ846) will be used by supervisors to monitor the 95-day period on all involved cases for the office. o NOTE: A 309 is not used in this process. Refer to 102.04.06 for acceptable verification documents. o When feasible, contact the individual to explain the action being taken and the information needed. 3. When the information is provided and the applicant(s) verification proves U.S. citizenship or qualified alien status, no further action is needed. Eligibility continues. Update MEDS to indicate citizenship or alien status is verified. 4. If the information is provided before the 90-day period ends and the individual is determined ineligible on citizenship or alien status, benefits must be terminated with advance notice at the time the determination is made. Do not wait until the 90 days end. 5. If, by the end of the reasonable opportunity period, the required verification has not been received or verifications are received and the person is determined ineligible, eligibility must be terminated no later than 30 days from the date the reasonable opportunity period ends. Advance notice of termination is required. o When eligibility has to be terminated at the end of the reasonable opportunity period, the action is taken without regard to the 12- month continuous eligibility provision for children or continuing eligibility for pregnant women. o Individuals who have received one reasonable opportunity period may receive it again. If an individual previously denied after reasonable opportunity period applies again and alleges change in citizenship status, Medicaid benefits can be authorized if eligibility is determined on all factors, excluding citizenship and qualified alien status. Document the case narrative when a 90-day period has been allowed.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |26 Effective Date: July 2025 Extension of Reasonable Opportunity Period Benefits are not terminated until the agency obtains verification of the individual’s status when the individual provides acceptable documents by the end of the reasonable opportunity period and verification by the agency is still in process. For example, the individual provides documents to establish his qualified alien status on the 90th day. The documents must be submitted through Homeland Security by DOM. Benefits would continue until verification of alien status is received from Homeland Security. A 30-day extension of the reasonable opportunity period is possible if the individual has verifiable, documented evidence a good faith effort has been made to obtain verifications, but documents have not yet been received. 102.04.06 EVIDENCE OF U. S. CITIZENSHIP Primary evidence has the highest reliability. Therefore, when the applicant or beneficiary presents any of the following primary documents the requirements for both citizenship and identity have been met and no further verification is needed. If any other level of evidence is used to verify U. S. citizenship, a second document verifying identity must be obtained. The following documents may be accepted as primary proof of an individual’s citizenship and identity. Primary Documents Explanation U. S. Passport A U. S. passport does not have to be currently valid to be accepted as evidence of U. S. citizenship as long as it was originally issued without limitation. On an emergency basis, the passport office will issue a U.S. passport without proof of citizenship. In this instance, the passport is issued with the limitation that it is valid for one year rather than the usual 5 or 10 years. When the holder of a passport with limitations returns to the country, he has to provide proof of citizenship to have the passport reissued without limitation. To determine if a passport was issued with limitation, compare the issuance date with the expiration date. If the expiration date is less than five years from the issuance date, the passport was issued with limitation and cannot be used as proof of citizenship. Each passport presented must be examined closely to determine whether or not the passport was issued with limitation. Spouses and children were sometimes included on one passport through 1980. U. S. passports issued after 1980 show only one person. Consequently, the citizenship and identity of the included person can be established when one of these passports is presented. NOTE: Do not accept any passport as evidence of U. S. citizenship

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |27 Effective Date: July 2025 when it was issued with a limitation. However, such a passport may be used as proof of identity. Primary Documents Explanation Certificate of Naturalization (N-550 or N-570) Issued by Department of Homeland Security (DHS) for Naturalization. Certificate of Citizenship (N-560 or N- 561) Issued By DHS to individuals who derive citizenship through a parent. A valid State-issued driver’s license if the State issuing the license requires proof of U.S. citizenship or obtains and verifies a SSN from the applicant who is a citizen before issuing such license Mississippi requires submission of a certified birth certificate and a Social Security card to obtain a Mississippi Driver’s License. The Department of Public Safety verifies that the SSN presented belongs to the individual and that the individual is a U.S. citizen using data provided by the Social Security Administration. Out of state driver’s license presented as proof of U.S. citizenship require verification from the issuing state that the individual’s U.S. citizenship was verified at the time the license was issued. Documentary evidence issued by a federally recognized Indian Tribe, including Tribes located in a State that has an international border, which: 1. Identifies the Federally recognized Indian Tribe that issued the document, 2. Identifies the individual by name, and 3. Confirms the individual’s membership, enrollment or affiliation with the Tribe. Documentary evidence includes, but is not limited to: A Tribal enrollment card; A Certificate of Degree of Indian Blood; A Tribal census document; Documents on Tribal letterhead, issued under the signature of the appropriate Tribal official, which meets the requirements of being issued by a federally recognized Indian Tribe that identifies the individual by name and confirms the individual’s membership, enrollment or affiliation with the Tribe. NOTE: The Bureau of Indian Affairs within the U.S. Department of the Interior publishes an updated listing of federally recognized Indian Tribes at least annually in the Federal Register. As of July 2018, there are 573 Tribal entities in the 48 mainland states. The Federal Register also lists Alaska Native entities that are federally recognized. Primary Documents Explanation A data match with the Social Security Administration See 102.04.02 for details of electronic verification through SVES and FDSH Verification with a state vital statistics agency documenting a record of birth This data is available through EVVE.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |28 Effective Date: July 2025 Verification through SAVE for a Naturalized Citizen Verification through the Department of Homeland Security’s Systematic Alien Verification for Entitlements (SAVE) database to verify U. S. citizenship for a naturalized citizen when original naturalization papers are not available. Secondary evidence of citizenship is documentary evidence of satisfactory reliability that is used when primary evidence of citizenship is not available within the reasonable opportunity period. In addition, a second document establishing identity must be presented. Secondary Documents Explanation A U.S. public birth record showing birth in one of the following: • One of the 50 U.S. States; • District of Columbia; • American Samoa • Swain’s Island • Puerto Rico (if born on or after January 13, 1941); • Virgin Islands of the U.S. (on or after January 17, 1917); • Northern Mariana Islands (after November 4, 1986 (NMI local time); A birth certificate may be issued by the State, Commonwealth, territory, or local jurisdiction. The birth record must have been recorded before the person was 5 years of age. A delayed birth record document recorded after 5 years of age is considered fourth level evidence of citizenship. ***NOTE: If the document shows the individual was born in Puerto Rico, the Virgin Islands of the U.S. or the Northern Marinara Islands before these areas became part of the U.S. the individual may be a collectively naturalized citizen. Collective naturalization occurred on

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |29 Effective Date: July 2025 Secondary Documents Explanation • Guam (on or after April 10, 1899) certain dates listed for each of the territories. Refer to the Citizenship Addendum at the end for information on collective naturalization. Eligible under the Child Citizenship Act of 2000 When a child derives U. S. citizenship from a parent and meets the requirements of the Child Citizenship Act of 2000, establish (1) the parent’s U. S. citizenship and (2) the child’s legal immigration status, if applicable, through SAVE to verify the child’s citizenship. Primary verification through a Certificate of Citizenship should be available if child was issued a Visa rather than a Permanent Resident Alien card upon entry into the country. Certification of Report of Birth Abroad (FS-1350) The Department of State issues a DS-1350 to U. S. citizens who were born outside the U. S. and acquired citizenship at birth, as verified by the information recorded on the FS-240, Consular Report of Birth Abroad. When the birth was recorded on the FS-240, certified copies of the Certification of Report of Birth Abroad can be obtained from the Department of State. The DS-1350 contains the same information as recorded on the current version of the Consular Report of Birth, FS-240. The DS-1350 is not issued overseas and can be obtained from the Department of State in Washington DC. Consular Report of Birth Abroad of a Citizen of the United States of America (FS-240) The Department of State consular office prepares and issues this document. A Consular Report of Birth can only be prepared at an American consular office overseas while the child is under the age of 18. While original FS- 240’s are not issued within the U.S, lost or mutilated documents can be replaced through the Department of State in Washington DC. Children born to military personnel are usually issued an FS-240. Certification of Birth Abroad (FS-545) Before November 1, 1990, the Department of State consulates also issued Form FS-545 along with the prior version of the FS-240. In 1990, U.S. consulates ceased to issue Form FS-545. Treat an FS-545 the same as a DS- 1350.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |30 Secondary Documents Explanation Certificate of birth in the U.S. This is a form created by the birthing hospital that is sent to Vital Records and used to create an official birth certificate. U. S Citizen ID Card (I-197) or prior version I-179 The former Immigration and Naturalization Service (INS) issued the I-179 from 1960 until 1973. It revised the form and renumbered it as form I-197. INS issued the I-197 from 1973 until April 7, 1983. INS issued Form I-179 and I-197 to naturalized U.S. citizens living near the Canadian or Mexican border who needed it for frequent border crossings. Although neither form is currently issued, either form that was previously issued is still valid. Northern Mariana Card (I-873) INS issued the I-873 to a collectively naturalized citizen of the U.S. who was born in the NMI before November 4, 1986. The card is no longer issued, but those previously issued are still valid. Final adoption decree The adoption decree must show the child’s name and U.S. place of birth. In situations where an adoption is not finalized and the State in which the child was born will not release a birth certificate prior to final adoption, a statement from a State-approved adoption agency that shows the child’s name and U.S. place of birth is acceptable. The adoption agency must state in the certification that the source of the place of birth information is an original birth certificate. Evidence of civil service employment by the U.S. government The document must show employment by the U.S. government before June 1, 1976. Official military record of service The document must show a U.S, place of birth (for example a DD-214 or similar official document showing a U.S. place of birth). Third level evidence of citizenship is documentary evidence of satisfactory reliability that is used when primary or secondary evidence of citizenship is not available. Third level evidence may only be used when primary and secondary evidence does not exist Effective Date: July 2025

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |31 Effective Date: January 2019 or cannot be obtained, and the applicant/beneficiary alleges being born in the U.S. In addition, a second document establishing identity must be obtained. Third Level Documents Explanation Medical records, including but not limited to, hospital, clinic, or doctor records or admission papers from a nursing facility, skilled care facility or other institution that indicates a U.S. place of birth. Do not accept a souvenir “birth certificate” issued by the hospital. Life or health or other insurance record which shows a U.S. place of birth. Life or health insurance records may show biographical information for the person including place of birth; the record can be used to establish U.S. citizenship when it shows a U.S. place of birth. Official religious record recorded in the U. S. showing that the birth occurred in the U.S. The record must be an official record with a religious organization. In questionable cases, i.e., religious document recorded near an international border, the religious record must be verified and/or verify that the mother was in the U. S. at time of birth. NOTE: Entries in a family Bible are not considered religious records. School records, including pre- school, Head Start and daycare, showing the child’s name and U.S. place of birth. The record must show the name of the child, the date of admission to the school, the date of birth (or age at the time record was created), and a U. S. place of birth. Fourth level evidence of citizenship is of the lowest reliability. It should only be used in the rarest of circumstances. It is used when primary evidence is not available and both secondary and third level evidence do not exist or cannot be obtained within the reasonable opportunity period and the applicant alleges a U. S. place of birth. In addition, a second document establishing identity must be obtained. Accept any of the following documents as fourth level evidence of U. S. citizenship if the document meets the listed criteria, the applicant/beneficiary alleges U. S. citizenship and there is nothing indicating the person is not a U. S. citizen or lost U. S citizenship. Fourth level evidence consists of documents established for a reason other

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |32 Effective Date: January 2019 than to establish U. S. citizenship and showing a U. S. place of birth. The U. S. place of birth on the document and documented place of birth on the application must agree. The written affidavit may be used only when the specialist is unable to secure evidence of citizenship in any other chart. Fourth Level Documents Explanation Federal or State census record showing U.S. citizenship or a place of birth (generally for persons born 1900 through 1950). The census record must also show the applicant’s age. NOTE: Census records from 1900 through 1950 contain certain citizenship information. To secure this information the applicant, beneficiary, or State should complete a Form BC-600, Application for Search of Census Records for Proof of Age. ADD in the remarks portion “U.S. citizenship data requested.” Also, add that the purpose is for Medicaid eligibility. This form requires a fee. Written Affidavit An affidavit signed by another individual under penalty of perjury who can reasonably attest to the applicant’s citizenship can be submitted with the applicant’s name, date of birth and place of U.S. birth. The affidavit does not have to be notarized. Citizenship Addendum Explanation If the document used to verify U. S. citizenship indicates the individual was born in Puerto Rico, the Virgin Islands of the U.S. or the Northern Marinara Islands before these areas became part of the U.S. the individual may Puerto Rico: Evidence of birth in Puerto Rico on or after April 11, 1899, and the applicant/beneficiary’s statement that he or she was residing in the U.S. possession or Puerto Rico on January 13, 1941; or Evidence that the applicant/beneficiary was a Puerto Rican citizen and the applicant/beneficiary’s statement that he or she was residing in Puerto Rico on March 1, 1917, and that he or she did not take an oath of allegiance to Spain.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |33 Effective Date: January 2019 Citizenship Addendum Explanation be a collectively naturalized citizen. Collective naturalization occurred on certain dates listed for each of the territories. U.S. Virgin Islands: Evidence of birth in the U.S. Virgin Islands and the applicant/beneficiary’s statement of residence in the U.S., a U.S. possession or the U.S. Virgin Islands on February 25, 1927; The applicant/beneficiary’s statement indicating resident in the U.S. Virgin Islands as a Danish citizen on January 17, 1917, and residence in the U.S., a possession or the U.S. Virgin Islands on February 25, 1927, and that he or she did not make a declaration to maintain Danish citizenship; or Evidence of birth in the U.S. Virgin Islands and the applicant/beneficiary’s statement indicating residence in the U.S., a U.S. possession or territory or the Canal Zone on June 28, 1932. Northern Mariana Islands (NMI) (formerly part of the Trust Territory of the Pacific Islands (TTPI)) Evidence of birth in the NMI, TTPI citizenship and residence in the NMI, the U.S., or a U.S. territory or possession on November 3, 1986 (NMI local time) and the applicant/beneficiary’s statement that he or she did not owe allegiance to a foreign state on November 4, 1986 (NMI local time);Evidence of TTPI citizenship, continuous residence in the NMI since before November 3, 1981 (NMI local time), voter registration prior to January 1, 1975 and the applicant/beneficiary’s statement that he or she did not owe allegiance to a foreign state on November 4, 1986 (NMI local time); or Evidence of continuous domicile in the NMI since before January 1, 1974 and the applicant/beneficiary’s statement that he or she did not owe allegiance to a foreign state on November 4, 1986 (NMI local time). NOTE: If a person entered the NMI as a nonimmigrant and lived in the NMI since January 1, 1974, this does not constitute continuous domicile and the individual is not a U.S. citizen.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |34 Effective Date: January 2019 102.04.07 EVIDENCE OF IDENTITY Proof of identity is required when primary evidence of citizenship cannot be obtained and a secondary, third or fourth level evidence is used. Identity Documentation Explanation The identity of all applicants and recipients must be verified. Documents submitted as proof of identity must have a photograph or other identifying information sufficient to establish identity, including, but not limited to, name, age, sex, height, weight, eye color or address. This section includes the following acceptable documents which may be used to verify the identity of any applicant or recipient. Documents may be recently expired provided there is no reason to believe the document does not match the individual. • A current state driver’s license issued by a state or territory. • School identification card. • U.S. military card or draft record. • Identification card issued by the Federal, State, or local government. • Military dependent’s identification card. • U.S. Coast Guard Merchant Mariner card. • For children under age 19, a clinic, doctor, hospital or school record, including preschool or day care records. • Two other documents containing consistent information that corroborates an applicant’s identity. Such documents include, but are not limited to, employer identification cards; high school or high school equivalency and college diplomas; marriage certificates; divorce decrees and property deeds or titles. • Finding of identity from a Federal or State governmental agency, including but not limited to a public assistance, law enforcement, internal revenue or tax bureau, or corrections agency, if the agency has verified and certified the identity of the individual. • If the applicant does not have any of the above documents, accept an affidavit signed, under penalty of perjury, by a person other than the applicant who can reasonably attest to the applicant’s identity. The affidavit must contain the applicant’s name and other identifying information establishing identity (name, age, sex, race, height, weight, eye color, address). The affidavit does not have to be notarized. Exception: Do not accept a Voter Registration Card or Canadian Driver’s License as identity verification. NOTE: Citizenship and/or identity do not have to be verified if the applicant is not otherwise eligible.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |35 Effective Date: June 2020 102.05 ALIEN STATUS The purpose of this section is to provide information and instructions for determining alien status and level of Medicaid coverage. In general, eligibility and level of coverage is based on the alien’s date of entry into the U. S., the date qualified alien status was obtained and/or the alien’s immigration status. Qualified Aliens Individuals living in the United States, who are not citizens, by birth or acquisition, and are not U. S. Nationals, are aliens. For Medicaid purposes, certain aliens are referred to as “qualified”, meaning they are potentially eligible for full Medicaid services just like U. S. citizens. Each applicant declaring to be a qualified alien is responsible to provide, or cooperate in obtaining, documentation of alien status. Qualified Aliens are divided into classifications that are eligible: • After a 5-year disqualification period, or • For up to a 7-year limit placed on their eligibility, or • Without a disqualification period or limit placed on their eligibility. NOTE: The 90-Day Reasonable Opportunity Period applies to otherwise eligible aliens who declare a qualified alien status and need time to obtain documentation that verifies their status. Refer to 102.04.05. Non-Qualified Aliens "Non-qualified aliens" are non-citizens potentially eligible only for Emergency Medicaid services. Non-citizens applying for Emergency Medicaid services are not required to disclose information regarding citizenship, alien status or enumeration and should not be requested to do so. All applicable program requirements must be met before an alien is eligible for either full Medicaid or Emergency Medicaid services. 102.05.01 CLASSIFICATIONS OF QUALIFIED ALIENS Eleven classifications of qualified aliens for the Medicaid Program are listed below. Some classifications contain special immigrant groups that are treated differently than the main classification in applying eligibility limits. Any differences in treatment are discussed in Sections 102.05.04 and 102.05.05 and are also included on the Alien Status Chart in Section 102.05.13, along with the documents needed for each classification and subgroup.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |36 Effective Date: June 2020 (1) AN ALIEN LAWFULLY ADMITTED FOR PERMANENT RESIDENCE (LPR) - Under the Immigration and Nationality Act (INA); (2) A REFUGEE - Admitted under Section 207 of the INA; (3) AN ALIEN GRANTED ASYLUM - Under Section 208 of the INA; (4) A CUBAN AND HAITIAN ENTRANT - As defined in section 501(e) of the Refugee Education Assistance Act of 1980; (5) AN ALIEN GRANTED PAROLE FOR AT LEAST ONE YEAR - Under Section 212(d)(5) of the INA; (6) AN ALIEN WHOSE DEPORTATION IS BEING WITHHELD - Under (1) Section 243(h) of the INA as in effect prior to April 1, 1997; or (2) Section 241(b)(3) of the INA, as amended; (7) AN ALIEN GRANTED CONDITIONAL ENTRY - Under Section 203(a)(7) of the INA in effect before April 1, 1980; (8) A BATTERED ALIEN - Meeting the conditions set forth in the Violence Against Women Act of 2000, PL 106-386, codified at 8 U.S.C. §1641. The term “qualified alien” includes an alien who has been battered or subjected to extreme cruelty in the U.S. by a spouse or a parent or by a member of the spouse or parent’s family residing in the same household as the alien. In order to be considered a battered alien, the alien must be either: o The person battered, o The parent of a child who is battered, or o A child whose parent has been battered. The battered alien must not be residing in the same household with the person responsible for the battery or extreme cruelty. If the battered alien resumes living with the one who is responsible for the battery or extreme cruelty, the battered alien’s eligibility ends the month after the month of reconciliation. (9) A VICTIM OF A SEVERE FORM OF TRAFFICKING In accordance with Section 107(b)(1) of the Trafficking Victims Protection Act of 2000, PL 106-86. An alien who is a victim of a severe form of trafficking is eligible to the same extent as an alien who is admitted to the U.S. as a refugee under section 207 of the Immigration and Nationality Act. (10) AMERICAN INDIAN BORN IN CANADA - Under Section 289 of the INA. American Indians born in Canada who are at least one-half American Indian blood and have established and maintained residence in the US since entry are qualified

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |37 Effective Date: July 2025 non-citizens. While regarded to have lawful permanent resident status, they are not in the LPR classification. As such, they are not subject to a 5-year waiting period. (11) CITIZENS OF THE FREELY ASSOCIATED (COFA) STATES OF MICRONESIA, REPUBLIC OF MARSHALL ISLANDS AND REPUBLIC OF PALAU -under Public Law 116-260, Division CC, Title II, Section 208, Consolidated Appropriations Act, 2021. Effective December 27, 2020, COFA migrants are qualified non-citizens without a 5-year waiting period. 102.05.02 GRANDFATHERED ALIENS Although not classifications of aliens, the following are groups of grandfathered aliens who are potentially eligible for benefits based on their arrival date into the U.S. 1. Effective 8/22/1996, the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) limited alien eligibility for Medicaid and other federal programs. Upon implementation, Mississippi elected to “grandfather” in aliens who were receiving and eligible for Medicaid on 08/22/1996. As a result, the grandfathered alien, who is lawfully residing in the U. S., has the right to have his eligibility continue under the alien policy in effect prior to 8/22/1996. He also retains grandfathered rights if benefits are terminated, and eligibility is later reestablished. 2. Aliens who entered the U.S. prior to 08/22/1996 and obtained qualified status prior to that date are considered to be a “qualified alien” under current policy and can qualify if otherwise eligible. 3. Aliens continuously present in the U.S. A qualified alien who entered the U.S. prior to 08/22/1996 and obtained qualified status on or after that date must have remained “continuously present” in the U. S. from their last date of entry into the country prior to 08/22/1996 until becoming a qualified alien. “Continuously present” in the U. S. is defined as the alien had: o No single absence from the U. S. of more than 30 days and, o No total of aggregate absences of more than 90 days. The qualified alien who meets the above definition is deemed to have entered the U. S. prior to 8/22/96 and if otherwise eligible, qualifies for full Medicaid. Aliens who were not “continuously present” are considered to have entered the U.S. on or after 8/22/96 and are evaluated according to their alien status.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |38 Effective Date: June 2020 102.05.03 ALIEN CLASSES SUBJECT TO A 5-YEAR DISQUALIFICATION PERIOD Aliens in the following classifications admitted to the U.S. on or after 08/22/1996 are subject to a 5-year disqualification period: • Lawful Permanent Resident Aliens; • Aliens Granted Parole for at Least One Year; • Battered Aliens; and • Conditional Entrants who entered the U.S. on or after 08/22/1996. The 5-year disqualification period is a period of time in which the individual is disqualified from receiving public benefits and is applicable as follows: • The first five years from the date they entered the country or • The first five years from the day they obtained qualified alien status, whichever is later. During this 5-year ban or disqualification period, these aliens are eligible only for emergency services if they meet all other eligibility requirements. 102.05.04 ALIEN CLASSES SUBJECT TO A 7-YEAR LIMIT ON ELIGIBILITY The 5-year disqualification does not apply to aliens in the following classifications, but these aliens are subject to a 7-year eligibility limit. The 7-year period is a point in time in which the alien may qualify for benefits, if otherwise eligible, provided application is timely filed. The 7-year period begins with either the date of entry into the U.S. or the date status is granted, as follows: • Refugees – can qualify until 7 years after the date of entry in the U.S.; NOTE: refugees assisted in MS by Catholic Charities will initially file an application for Medicaid as a refugee with the RO. If denied, the refugee will be evaluated for time-limited Medicaid coverage under the Refugee Resettlement Grant by the grant holder, the Department of Child Protection Services. • Asylees – can qualify until 7 years after the grant of asylum; • Cuban and Haitian Entrants – can qualify until 7 years after grant of that status; • Aliens Whose Deportation is Being Withheld – can qualify for the first 7 years after grant of deportation withholding;

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |39 Effective Date: June 2020 • Aliens Admitted to the Country as Amerasian Immigrants – can qualify for 7- years from entry into the U.S. Although not listed as a distinct classification of qualified alien, these aliens are categorized as a group of aliens who can qualify for up to 7 years from the date of entry in the U.S.; • Victims of Trafficking and Their Derivative Beneficiaries – can qualify during the first 7 years after obtaining victim status; • Iraqi and Afghan Special Immigrants are treated as refugees and can qualify until 7 years from the date of entry into the U.S. Eligibility must terminate the month following the end of the 7-year period unless the alien’s status has changed to a classification not subject to the 7-year limitation. If the time-limited alien’s status adjusts to Lawful Permanent Resident (LPR) during the 7- year period, the alien can continue to be eligible for the remainder of the 7-year period. To continue to be eligible beyond the 7-year period, the alien must be credited with 40 Qualifying Quarters of coverage, as outlined in 102.05.05. 102.05.05 ALIENS EXEMPT FROM THE 5-YEAR DISQUALIFICATION AND THE 7-YEAR LIMIT The following groups of qualified aliens are exempt from both the 5-year disqualification and the 7-year eligibility time limit and if otherwise eligible, qualify for full Medicaid: • Any qualified alien who is also: o An honorably discharged veteran, or o On active duty in the U. S. military, or o The spouse (including a surviving spouse who has not remarried) or o An unmarried dependent child of an honorably discharged veteran or individual on active duty in the military. • Grandfathered aliens: o Aliens eligible for and receiving Medicaid on 8/22/96; o Aliens who entered the U. S. and obtained qualified status prior to 08/22/1996; o Aliens who entered the U. S. prior to 08/22/1996, obtained qualified status on or after 08/22/1996, and remained “continuously present” in the U. S. as defined in 102.05.02.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |40 • Ukrainian nationals paroled into the US on or between February 24, 2022, and September 30, 2024, are qualified non-citizens eligible to the same extent as refugees. Ukrainian nationals paroled after September 30, 2023, who are the spouse or child of the parolee above or are the parent, legal guardian or primary caregiver for the parolee above who entered as an unaccompanied minor are also eligible to the same extent as refugees. However, this special group is not subject to the 5-year bar and not limited to 7 years of eligibility. • COFA migrants are considered qualified non-citizens. This classification is not subject to 5-year bar or the 7-year eligibility limit. American Indians born in Canada who meet applicable criteria are regarded as lawful permanent residents. This classification is not subject to the 5-year bar or limited to 7 years of eligibility. NOTE: Aliens filing an application for Emergency Medicaid services only are not subject to either the 5-year disqualification or 7-year time limit. 102.05.06 REQUIREMENT FOR 40 QUALIFYING QUARTERS At the end of the 5-year disqualification period an alien classified as lawfully admitted for permanent residence (LPR) is potentially eligible for full Medicaid benefits only if the individual can be credited with 40 qualifying quarters (QQs) of earnings covered by Social Security or can be credited with 40 QQs which satisfy the requirement. NOTE: If 40 QQs cannot be credited, determine if the alien is exempt due to having grandfathered status or veteran or active-duty military status (including certain family members). Exempt individuals are not required to have 40 QQ’s. If not exempt, the LPR remains potentially eligible for Emergency Medicaid only. All classes of aliens who are subject to the mandatory 5-year disqualification period are not eligible for full Medicaid for the first 5 years, even if they can be credited with 40 qualifying quarters prior to or during the 5-year disqualification period. The disqualification period must be imposed before an assessment of eligibility based on the 40-quarter requirement. Alien classifications of granted parole for at least one year, battered aliens and aliens granted conditional entry are not required to have 40 Qualifying Quarters of coverage in order to qualify for Medicaid but are subject to the 5-year bar. Effective Date: July 2025

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |41 Effective Date: June 2020 102.05.06A 40 QUALIFYING QUARTERS OF EARNINGS A qualifying quarter means a quarter of coverage as defined under Title II of the Social Security Act, which is worked by the alien, and/or: • All the qualifying quarters worked by the spouse of the alien during their marriage, provided the alien remains married to the spouse or the marriage ended by death and not divorce, and • All of the qualifying quarters worked by a parent of an alien while the alien was under age 18. The alien does not have to be under age 18 at the time of the application. Combining Quarters Subject to the limitations above, the alien’s own QQs can possibly be combined with those of his parent(s) and/or spouse to attain the required 40 quarters. Receipt of Means-Tested Benefits After December 31, 1996, any quarter in which any of these individuals, i.e., the alien, his parent(s) and/or spouse, received Federal means-tested benefits, such as TANF, SSI and Medicaid, cannot be credited to meet the 40-quarter requirement. When total qualifying quarters have been verified, quarters in which Federal means- tested benefits were received by any person contributing quarters should be subtracted from the total to determine the number of countable qualifying quarters. 102.05.06 B PROCEDURES TO VERIFY 40 QUALIFYING QUARTERS Utilize the following procedures to verify 40 QQs of earnings: • Determine the individuals whose quarters can be included in the QQ count based on the requirements and limitations outlined above in 102.05.06A. Question the applicant to determine that proper relationships exist, the date of birth of the applicants and request Social Security Numbers for each individual included. • Determine if it is possible for the applicant to meet the requirement. Ask how many years the applicant and each individual included in the quarter coverage calculation have lived in the U.S. If the total is less than 10 years (40 quarters), the applicant cannot meet the requirement.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |42 Effective Date: June 2020 • If the total number of years is at least 10, determine how many years included earnings. Always determine the applicant’s own quarters first. Many applicants may have sufficient quarters on their own record, and it will not be necessary to request earnings history for other individuals. If the applicant does not have sufficient quarters, determine the quarters for the other individuals. • Request a quarter coverage history from the Federal Data Services Hub unless it is clear from the interview that the applicant, or applicant in combination with others, cannot meet the 40-quarter requirement. If the applicant still believes he meets the 40-quarter requirement, request a quarter coverage history. • When verification is received from the FDSH, total the quarters. Do not count any quarter(s) in which federal means-tested benefits were received by the individual as a QQ. 102.05.07 ENUMERATION EXCEPTION FOR QUALIFIED ALIENS The requirement to apply for a Social Security Number has certain exceptions, as outlined in 102.06. If an alien in a qualified status meets an exception, a SSN is not required to qualify for Medicaid. For example: an alien in a qualified alien status applies for Medicaid but does not have Department of Homeland Security (DHS) work authorization and therefore does not have a SSN. This condition meets a Medicaid enumeration exception and applying for a SSN is not required. NOTE: The Social Security Administration is permitted to issue a SSN for non-work purposes in order for the alien to obtain public assistance; however, the requirement to file for a “non-work” SSN is a Medicaid exception to the requirement to file for a SSN. In the event a non-work SSN is furnished at the time of application for Medicaid, include the SSN with other alien status documentation for verification with DHS. If an individual is admitted to the U. S. and not authorized to work, DHS verification will include this information with returned FDSH or SAVE verification. If the alien’s status requires 40 Qualifying Quarters of coverage, the SSN’s of the spouse or parent with the work history must be furnished in order for Medicaid to verify the needed 40 QQ’s with SSA. If SSN’s are not provided because an exception

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |43 Effective Date: June 2020 exists for furnishing a SSN or the spouse or parent of the applicant is not applying and the 40 QQ’s provision applies, it will be the responsibility of the alien applying for coverage to obtain the verification of QQ’s from SSA. 102.05.08 ELECTRONIC VERIFICATION OF ALIEN STATUS The primary data source for verifying alien status is the VLP (Verify Lawful Presence) function through the FDSH. The secondary electronic data source is the SAVE (Systematic Alien Verification for Entitlements) process. Both data sources are used to verify: (1) the authenticity of the alien’s USCIS documents, (2) his date of admission to the U.S. and (3) current immigration status. Electronic verification is used for documented aliens who are applying for benefits. Aliens applying for Emergency Medicaid services only are not subject to the electronic verification of status. 102.05.08A PROCEDURES FOR OBTAINING ELECTRONIC VERIFICATION FOR ALIENS Electronic verification is obtained by State Office after receipt of a request from an RO. The verification process is as follows: Medicaid Specialist Responsibilities: • Request the alien’s original immigration documents issued by the immigration agency. Currently, the United States Citizenship and Immigration Services (USCIS), within the Department of Homeland Security is responsible for immigration. • Complete the INS Verification cover sheet for each documented alien requesting benefits, providing the person’s full name, Medicaid ID number, alien registration number, nationality, date of birth, Social Security Number, and county of residence. Include known information regarding the alien’s status as a veteran or active-duty member of the military or American Indian born outside the U.S. • Attach front and back copies of original immigration documents and attach a copy of the alien’s Social Security card. • Submit the information to state office.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |44 Effective Date: June 2020 State Office Responsibilities: When the information is received in state office, it is submitted electronically to the Department of Homeland Security, using the FDSH or SAVE process, as appropriate. When a response is received back, it is reviewed initially at the state level. The reviewer notes the following: • Whether or not the alien is qualified, and • If he is a qualified alien, whether the 5-year disqualification or 7-year eligibility time limit appears applicable. • If either the 5- year ban or 7-year eligibility period appears applicable, the reviewer notes the beginning and ending dates and forwards the information to the regional office. • If additional documentation is needed, such as for a battered alien or victim of trafficking, the RO will be notified of the need for additional documents. Medicaid Specialist Responsibilities Following State Office Review • When the INS verification sheet is received from state office and the alien is not in a qualified alien classification, he is eligible only for Emergency Services. • When the INS verification sheet is received from state office and the alien is in a qualified status, review it and compare the INS information and case record information with the chart in Section 102.05.15 to determine alien eligibility and correct level of Medicaid eligibility. • The state reviewer does not have access to all information in the case record; therefore, it is very important that the specialist considers information from all applicable sources and applies the correct policy to make an eligibility determination. Example: The SAVE verification sheet from the Department of Homeland Security verifies an alien was Lawfully Admitted for Permanent Residence and is in the 3rd year of the 5-year ban. The state reviewer specifies the full 5-year period on the form. However, the case contains verification that the alien is the pregnant spouse of an honorably discharged veteran. The specialist determines the qualified alien is exempt from the 5-year disqualification and eligible for Medicaid as a pregnant woman in a full-service COE.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |45 Effective Date: July 2025 Re-Verification of Alien Status Once alien status has been verified, it is not necessary to re-verify unless the alien status is subject to change. Examples of when alien status is subject to change include, but are not limited to, the following: 1) An individual admitted under a temporary status may change to lawful permanent resident status. 2) An individual admitted under a temporary status that has expired may have updated his status. 3) A refugee may change his alien status to lawful permanent resident status. 4) An individual may meet requirements as a battered alien or some other type of qualified alien status. 5) An illegal alien may change to a legal status. 102.05.08B VERIFICATION PROCEDURES FOR GRANDFATHERED ALIENS A “grandfathered alien” is an individual who is lawfully residing in the U. S. and is in one of the 3 categories of grandfathered aliens described in 102.05.02. When there is an indication an alien is potentially “grandfathered”, the specialist must: • Request immigration documents, • Request electronic verification of alien status as outlined in 102.05.08A, and • Establish eligibility as a grandfathered alien in one of the 3 allowable categories: o Establish eligibility on 08/22/1996 in MS or another state. If eligible in MS, verify eligibility using MESA data for the record. If eligible in another state, make telephone contact with the other state to confirm eligibility on 08/22/1996 and document the contact with the name/title of the person providing the verification. This is sufficient to establish eligibility in the grandfathered class of eligible and receiving as of 08/22/1996. All other factors of eligibility must be met. o Verification from DHS will verify qualified alien status established prior to 08/22/1996. DHS verification is the only documentation needed to establish eligibility in the grandfathered class of those who entered prior to 08/22/1996. All other factors of eligibility must be met. o Verify “continuously present” by requesting documentation that the alien lived in the U.S. continuously from prior to 08/22/1996 until qualified alien status was granted. Various forms of documentation, including utility

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |46 Effective Date: June 2020 bills, may be accepted. NOTE: if the individual has or can be credited with 40 QQ’s, do not verify continuous presence. All other factors of eligibility must be met. 102.05.08C VERIFICATION PROCEDURES FOR VICTIMS OF TRAFFICKING Victims of trafficking and their derivative beneficiaries qualify for Medicaid during the first 7 years after obtaining this qualified status. The FDSH may verify the lawful presence of a trafficking victim, in which case no further verification is needed. It is not possible to verify victims of trafficking using SAVE. If electronic verification is not possible, obtain a copy of the Certification or Eligibility letter issued by the Office of Refugee Resettlement (ORR) within the Department of Health and Human Services. These letters confirm that a child or adult is a victim of trafficking. The ORR letter is acceptable verification of qualified alien status for a trafficking victim. 102.05.08D VERIFICATION PROCEDURES FOR BATTERED ALIENS Battered aliens may qualify after the expiration of the 5-year disqualification period. The FDSH or SAVE may verify the lawful presence of a battered alien, in which case no further verification is needed. However, if electronic verification is not possible, the documents that are needed are those listed in the chart at 102.05.13, Alien Status Chart. NOTE: A battered spouse, child or parent may file an immigrant visa petition under the INA, as amended by the Violence Against Women Act (VAWA). The VAWA provisions allow certain spouses, children and parents of U.S. citizens and certain spouses and children of Lawfully Permanent Residents (LPR’s) to file a petition individually without the abuser’s knowledge. This allows victims to seek both safety and independence from their abuser, who is not notified of the filing. The alien must also be able to show a substantial connection between the battery or extreme cruelty and the alien’s need for Medicaid. This may include such reasons as Medicaid is needed to obtain medical attention or mental health counseling caused by abuse, to replace medical coverage and/or health services lost when the individual separated from the abuser, to enable the individual to become self-sufficient following separation from the abuser or to provide medical care during a pregnancy resulting from the abuser’s sexual assault or abuse of, or relationship with, the individual.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |47 Effective Date: June 2020 102.05.08 E VETERANS, ACTIVE-DUTY MILITARY AND FAMILY MEMBER REQUIREMENTS To be eligible as a veteran, the qualified alien must have been honorably discharged, not based on alienage, and must have fulfilled minimum active-duty service requirements. A qualified alien who is an active-duty member of the Armed Forces, but not on active duty for training purposes only, can also be eligible. A qualified alien who is the spouse of a veteran or active-duty service member may be eligible. The veteran’s exemption also includes the unmarried surviving spouse of a veteran or active-duty military person. To qualify as a surviving spouse, at least one of the following conditions must be met: • The spouse must have been married to the veteran for at least one year; or • The spouse must have had a child with the veteran, or • The veteran’s death must have been due to an injury or illness incurred during military service and the marriage must have been in existence sometime within 15 years after the period of service in which the injury or disease was incurred or aggravated. Loss of Exemption Surviving spouses who remarry lose the benefit of this exemption the month after the month of the remarriage. Spouses whose marriage ended in divorce lose the benefit of this exemption the month after the month of divorce. Qualifying Children To qualify as a child of a veteran or active-duty service person, the biological, adopted or stepchild must be • Unmarried and claimable as a dependent on the military person’s tax return and Under 18 years of age or under 22 and a student regularly attending school; or • A child with disabilities who is over 18, if the child had a disability and was dependent on the veteran or active-duty service member before the child’s 18th birthday; or • A surviving unmarried minor child of a veterans or person killed in active duty and dependent on the veteran at the time of the veteran’s death.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |48 Effective Date: June 2020 102.05.09 NON-QUALIFIED ALIENS An alien who does not meet the specific requirements of a qualified alien is a non- qualified alien for Medicaid purposes. A non-qualified alien who meets MS residency requirements and other applicable eligibility factors can receive Medicaid Emergency Services only. An applicant for Emergency Medicaid services is not required to provide information regarding citizenship, immigration or enumeration and should not be requested to do so. Electronic verification of alien status is not used for a non- qualified alien. Illegal Aliens Illegal aliens are non-qualified aliens. This group of individuals includes: • Undocumented aliens who entered illegally without knowledge of USCIS; or • Aliens who were admitted for a limited period of time and did not leave the U. S. when the period of time expired. These individuals, if they meet all eligibility criteria except citizenship/alien status, are entitled to Medicaid only for treatment of an emergency medical condition. The specialist must accept the applicant’s statement if they say they have no documentation and assess the alien for emergency services only. Undocumented and illegal aliens do not have to provide a Social Security Number or provide information regarding citizenship or immigration status. The alien status of an illegal alien is not verified through an electronic verification process. Ineligible Aliens Ineligible aliens may be lawfully admitted to the U. S., but only for a temporary or specified period of time. These aliens are never qualified aliens, Because of the temporary nature of their admission status, most ineligible aliens are not entitled to any Medicaid benefits, including emergency services. However, in some instances, an alien in a currently valid non-immigration status may meet state residency requirements, such as intent to reside in MS for purposes of employment. If state residency requirements are met, the alien is potentially eligible for Emergency Medicaid services only.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |49 Effective Month: September 2018 Examples of Ineligible Aliens Who are Lawfully Admitted Foreign Students Visa, Passports or Form I-766 OR Visitors Tourists Form I-94, Arrival/Departure Record annotated with A to M OR Foreign government representatives on official business and their families and servants Form I-688, Temporary Resident Card annotated with Section 210 or 245A OR Crewmen on shore leave International organization representatives and their families and servants Temporary workers (individuals allowed entry temporarily for employment purposes) Form I-688 A and B, Employment Authorization Card OR Form I-185, Canadian Border Crossing Card OR Members of the foreign press, radio, film, etc., and their families Form I-186, Mexican Border Crossing Card OR Short-term parolees Form SW 434, Mexican Border Visitor’s Permit OR Form I-95-A, Crewman’s Landing Permit Note: Form I-94, Arrival-Departure Record, is also issued for refugees and other related statuses.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |50 Effective Month: September 2018 Other Aliens Aliens who are admitted legally to the U. S., but do not fall into one of the specific categories of qualified aliens are non-qualified aliens. These individuals may include Legal Temporary Residents (LTR’s), as well as individuals who are given temporary administrative statuses, i.e., a stay of deportation or voluntary departure until they can formalize permanent status or individuals who are paroled for less than one year or aliens under deportation procedures. Immigration Reporting Applicants who are found to be in the U. S. illegally through the application process are not subject to immigration reporting requirements. Persons who apply for benefits on behalf of others, i.e., a mother applying for her children, are not subject to immigration reporting requirements. Declining to provide documentation of immigration status is not a valid reason to report an alien to immigration. The alien applicant who declines to present documentation of qualified alien status or a Social Security Number (unless an enumeration exception exists) will only be able to receive Emergency Medicaid, if otherwise eligible. In this instance, there is no reason to seek further verification of alien status beyond interviewing the applicant. All rules of confidentiality must be applied in regard to an individual’s alien status. 102.05.10 EMERGENCY MEDICAL SERVICES PROCESS Aliens who are not entitled to full Medicaid benefits may be eligible for emergency services only, if the following conditions exist: • All other eligibility requirements are met except satisfactory immigration status; • Care and services needed are not related to an organ transplant procedure or routine prenatal or postpartum care;

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |51 Effective Month: September 2018 • The alien has, after sudden onset, a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: o Placing the patient’s health in serious jeopardy, o Serious impairment to bodily functions, o Serious dysfunction of any bodily organ or part, or o Is for labor and delivery NOTE: The services provided in this situation must relate to the injury, illness, or delivery causing the emergency. Services that are not directly related to the injury, illness, or delivery are not compensated by Medicaid. Once the medical condition is stabilized, even if it remains serious or results in death, it is no longer an emergency. Procedures for Processing Eligibility for Emergency Medicaid Services At the point of application, the Medicaid eligibility worker must explain to the applicant, who is a non-qualified alien or a qualified alien subject to 5-year disqualification, that if all applicable program eligibility requirements are met, Medicaid may reimburse for emergency services only (including labor and delivery) after the services have been received. Determining Eligibility for Emergency Medicaid Services When determining eligibility for Medicaid coverage for treatment of an emergency medical condition only, the specialist will obtain information to (1) Establish eligibility based on emergency services criteria, such as a copy of the hospital bill or other documentation from the hospital indicating treatment or services received, dates of service and the diagnosis for the individual’s condition and (2) Establish eligibility on technical factors and financial factors, except citizenship, alien status and enumeration. Not Financially Eligible If the alien is not financially eligible based on income for MAGI and ABD and resources, if ABD rules apply, the application will be denied by the specialist.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |52 Effective Month: September 2018 Applicant Appears Eligible for Emergency Medicaid Services If the specialist determines the individual appears eligible for emergency services, the case will be processed as outlined in Chapter 400, Section 400.09. Specifically: • Regional Offices process and authorize applications for emergency medical services for aliens requiring emergency labor and delivery services, and, • State Office authorizes eligibility for all other emergency conditions based on documentation of the emergency medical condition as secured by the RO. Pertinent material from the case record, including a copy of the application, a budget and medical documentation, will be sent to state office. 102.05.11 BUDGETING FOR CITIZEN CHILDREN OF NON-QUALIFIED ALIEN(S) Children born in the United States to parent(s) in a non-qualified alien status may be eligible for full Medicaid. To determine eligibility, count the needs and income of the parent(s) as well as any siblings using appropriate MAGI or ABD budgeting rules. The parent(s) and any sibling(s) who are non-qualified aliens cannot be eligible for full Medicaid benefits; however, they may be assessed for Emergency Medicaid Services. A child born to a mother eligible for emergency services for labor and delivery is deemed eligible for Medicaid through the month of the child’s first birthday, provided the child remains a resident of the state. When the child reaches the age of one, a review is required. Verifications postponed during the deemed eligible child’s first year must be provided. To determine eligibility after the deemed period, count the needs and income of the parent(s) as well as any siblings using appropriate MAGI or ABD budgeting rules. As stated, the parent(s) and any sibling(s) who are non-qualified aliens cannot be eligible for full Medicaid benefits; however, they may be assessed for Emergency Medicaid Services. 102.05.12 PUBLIC CHARGE Aliens who seek admission to the U.S. must establish that they will not become ‘public charges.’ A “public charge” is an alien who has become (for deportation purposes), or who is likely to become (for admission/adjustment purposes), solely dependent on government assistance as demonstrated by receipt of: • Medicaid with exceptions for emergency services, coverage of pregnant women and coverage of children under age 21,

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |53 Effective Month: September 2018 • SNAP (Supplemental Nutrition Assistance Program), • Public Housing or Section 8 housing vouchers, • Cash assistance through SSI or TANF (non-cash TANF benefits exempted). Many aliens establish that they will not become public charges by having ‘sponsors’ who pledge to support them. Aliens may ask staff about the consequences of becoming a public charge by applying for assistance. This is of concern to aliens who want to become Legal Permanent Residents and obtain a Green Card. It should be noted that the public charge rule does not apply to: • refugees and persons granted asylum with pending or approved applications for status, • Victims of Trafficking, or criminal activity or individuals classified under the Violence Against Women Act, • Military service members and their spouses and children. The law requires that USCIS officials consider the totality of an individual’s circumstances when making a public charge determination, such as age, income, education and skills, health, family size and affidavits of support (sponsors). Receipt of government assistance is also taken into consideration. Each determination is made on a case-by-case basis and the regional office is not involved in this determination. Specialists will determine eligibility for aliens that are not exempt from the public charge rule following all requirements for Medicaid. 102.05.13 ALIEN STATUS CHART OVERVIEW OF ALIEN ELIGIBILITY FOR MEDICAID VERIFICATION DOCUMENTATION FOR ALIENS SUBJECT TO 5-YEAR DISQUALIFICATION ALIEN STATUS ELIGIBILITY STATUS • I-551 (Alien Registration Receipt Card) commonly referred to as the “green card” • Foreign passport stamped with an un-expired temporary I-551 stamp LAWFULLY ADMITTED FOR PERMANENT RESIDENCE (LPR) LPR is only classification required to have 40 QQ’s after the 5-year disqualification period.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |54 Effective Month: September 2018 OVERVIEW OF ALIEN ELIGIBILITY FOR MEDICAID • I-94 annotated stamped with a temporary I-551 stamp (for recent arrivals or aliens who have applied for a replacement I-551) Parolee, Conditional Entrant & Battered Alien are not required to have 40 QQ’s but are subject to the 5- year disqualification period. LPR, Parolee, Conditional Entrant & Battered Alien are eligible for emergency services only during the 5- year disqualification period. LPR, Parolee, Conditional Entrant & Battered Alien are exempt from 5-year disqualification period if in a grandfathered status or a veteran or active-duty military member or family member. • I-94 annotated with stamp showing grant of parole under 212(d)(5) and a date showing granting of parole for at least one year. (Applicant cannot aggregate periods of admission for less than one year to meet the one- year requirement) PAROLEE NOTE: Iraqi/Afghan Special Immigrants and Ukrainian Humanitarian Parole are addressed below) • I-94 with stamp showing admission under 203(a)(7) of the INA, refugee- conditional entry • I-688B (Employment Authorization Card) annotated 274a.12(a)(3) • I-766 (Employment Authorization Document) annotated “A3” CONDITIONAL ENTRANT I-797 indicating filing under one of the provisions listed below and approval of the petition or a finding that a prima facie case has been established. BATTERED ALIEN Includes battered alien’s child and parent of a battered alien child

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |55 Effective Month: September 2018 OVERVIEW OF ALIEN ELIGIBILITY FOR MEDICAID • Case Type: I-130 petition approved • Case Type: I-360 petition approved • I-551 (Resident Alien Card or Alien Registration with one of the following classes of admission (COA) codes stamped on lower left side of the back of a pink card demonstrates approval of a petition under C.3.j.(1)3. Above: IB1- IB3, IB6-IB8, B11, B12, B16, B17, B20-B29, B31-B33, B36-B38, BX1-BX3, or BX6-BX8 • Order from an immigration judge (EOIR) or the Board of Immigration Appeals granting suspension of deportation or cancellation of removal under VAWA (EOIR) Form 42B or an order from an immigration judge (EOIR) or Board of Immigration If an alien claiming pending or approved battered status presents a code different than those listed, or if unable to determine the class of admission from the I-551 stamp, send a copy of the document(s) presented to USCIS with completed INS Verification cover sheet to state office. VERIFICATION DOCUMENTATION FOR ALIENS WITH 7-YEAR ELIGIBILITY LIMIT ALIEN STATUS ELIGIBILITY STATUS • I-94 stamped showing admission under section 207 of the INA and date of entry to the United States • I-688B (Employment Authorization Card) annotated 274a.12(a)(3) • I-766 (Employment Authorization Document) annotated “A3” REFUGEE Can qualify for full Medicaid until 7 years after date of entry even if individual adjusts to LPR status during the 7-year period.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |56 Effective Month: September 2018 OVERVIEW OF ALIEN ELIGIBILITY FOR MEDICAID • I-571 (Refugee Travel Document) Refugees become eligible to apply for adjustment to LPR status after 12 months in the U. S., but it takes another 6 – 12 months to be approved. They are still considered refugees for eligibility purposes when they have an I-551 with a code of RE-6, RE-7, RE-8 or RE-9) After 7 years, must have adjusted to LPR with 40 QQs to establish continued eligibility. 5-Year disqualification period does not apply. If ineligible for ongoing Medicaid, the individual may be eligible for full benefits for 8 months beginning with date of entry through the Refugee Resettlement Grant. • Iraqi or Afghan passport with an immigrant visa stamp noting that the individual has been admitted under IV (Immigrant Visa) and DHS stamp or notation on passport code SI-1,2,3: SQ-1,2,3. • I-94 showing date of entry with SQ-4, 5 • I-551 (green card) showing Iraqi or Afghan nationality with an IV Immigrant Visa SI-6,7,8: SQ-6,7,8,) IRAQI & AFGHAN SPECIAL IMMIGRANTS (Includes spouse and unmarried children under age 21) • I-94 stamped showing grant of asylum under section 208 of the INA and date of entry • A grant letter from the Asylum Office of the USCIS • I-688B (Employment Authorization Card) annotated “274a.12(a)(5)” • I-766 (Employment Authorization Document) annotated “A5” • Court order of an immigration judge showing asylum granted under section 208 of the INA ASYLEE • I-551 (Alien Registration Receipt Card) with the code CU6, CU7, or CH6 CUBAN/HAITIAN ENTRANT

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |57 Effective Month: September 2018 OVERVIEW OF ALIEN ELIGIBILITY FOR MEDICAID • Foreign passport stamped with an unexpired temporary I-551 stamp with the code CU6 or CU7 • I-94 stamped with an unexpired temporary I-551 stamp with the code CU6 or CU7 • I-94 with stamp showing parole as “Cuban/Haitian Entrant” under Section 212(d)(5) or the INA. • I-551 with code AM6, AM7, or AM8 • Foreign passport stamped with an unexpired temporary I-551 stamp with the code AM1, AM2, or AM3 • I-94 stamped with an unexpired temporary I-551 stamp with the code AM1, AM2, or AM3 AMERASIAN IMMIGRANTS VERIFICATION DOCUMENTATION FOR ALIENS WITH 7-YEAR ELIGIBILITY LIMIT (Continued) ALIEN STATUS ELIGIBILITY STATUS Office of Refugee Resettlement (ORR) certification letter VICTIM OF A SEVERE FORM OF TRAFFICKING Eligible for benefits to the same extent as a refugee. Eligible for any Medicaid category if meets all other eligibility criteria. Victims of Trafficking and their derivative beneficiaries qualify during the first 7 years after status is obtained. After 7 years, must have adjusted to LPR with 40 QQs to establish continued eligibility. 5-Year disqualification period does not apply.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |58 Effective Month: September 2018 OVERVIEW OF ALIEN ELIGIBILITY FOR MEDICAID • Order of an immigration judge showing deportation withheld under section 243(h) of INA as in effect prior to April 1, 1997, or removal withheld under Sec. 241(b)(3) of the INA and date of grant • I-688B (Employment Authorization Card) annotated 274a.12(a)910) • I-766 (Employment Authorization Document) annotated “A10” DEPORTATION WITHHELD Can qualify for full Medicaid until 7 years after the grant of withholding even if individual adjusts to LPR during the 7-year period. After 7 years, must have adjusted to LPR with 40 QQs to establish continued eligibility. The 5-Year disqualification period does not apply. VERIFICATION DOCUMENTATION FOR ALIENS EXEMPT FROM 5-YEAR DISQUALIFICATION AND EXEMPT FROM 7- YEAR ELIGIBILITY LIMITATION ALIEN STATUS ELIGIBILITY STATUS • Green Form DD-2 marked “ACTIVE” OR • Current orders showing the individual is on full-time duty in the US Army, Navy, Air Force, Marine Corps, or Coast Guard (Reserves are not considered active duty.) ACTIVE-DUTY MILITARY Includes spouse and unmarried dependent children under 18 or under 22 and a student Eligible for any Medicaid category if all other eligibility criteria are met. 5-Year disqualification period does not apply. 7-year limitation on eligibility does not apply. • DD-214 indicating honorable discharge, OR Discharge papers indicating honorable discharge VETERAN Includes spouse and unmarried dependent children under 18 or under 22 and a student

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |59 Effective Month: September 2018 OVERVIEW OF ALIEN ELIGIBILITY FOR MEDICAID Active-duty military or veteran status exempt from 40 QQ’s requirement. If LPR does not have 40 QQ’s, determine if veteran or active-duty military, spouse or unmarried dependent provision applies • I-94 arrival/departure record with FSM-Federated States of Micronesia, or CFA with MIS – Marshall Islands • Unexpired foreign passport stamped CFA-MIS, CFA-FSM, CFA- RMI, CFA-PAL • I-766 or I-688B Employment Authorization Document (EAS) annotated “274a.12(a)(8)” or” A8” COMPACT OF FREE ASSOCIATION (COFA) MIGRANT Provision effective December 2020 or after for citizens of the Freely Associated States of Micronesia, Marshall Islands or Palau residing in the US. 5-year bar does not apply. 7-year eligibility limit does not apply. Evaluate for any Medicaid category. • Canadian passport stamped with an unexpired temporary I-551 stamp S- 13 • A letter or other tribal document certifying at least 50% American Indian blood as required by section 289 of the INA, combined with a birth certificate or other satisfactory evidence of birth in Canada AMERICAN INDIAN BORN IN CANADA To be regarded as lawfully admitted for permanent residence, the person in this classification must meet the conditions: • Canadian-born • At least 50% American Indian blood • Maintained residence in the US since entry. These individuals are regarded as having been

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |60 Effective Month: July 2025 OVERVIEW OF ALIEN ELIGIBILITY FOR MEDICAID lawfully admitted but are not in the LPR classification. 5-year bar does not apply. 7-year eligibility limit does not apply. • I-94 noting humanitarian parole per INA section 212(d) (50 or 8 USC 1182(d)(5) • Foreign passport with DHS/CBP admission stamp noting “DT” • Foreign passport with DHS/CBP admission code noting Uniting for Ukraine or U4U” • Foreign passport with DHS/CBP admission stamp noting Ukrainian Humanitarian Parole or “UHP” • For I-765 Employment Authorization Document (EAD) receipt notice with code C11 HUMANITARIAN PAROLE- UKRAINE Ukrainian nationals who enter the US as parolees on or between February 24, 2022, and September 30, 2024, are considered qualified non-citizens and are eligible to the same, extent as refugees. Ukrainian nationals who are paroled into the US after September 30, 2023, and who are the spouse or child of a parolee described above, or who is the parent, legal guardian or primary caregiver of a parolee described above who is determined to be an unaccompanied child will also be eligible to the same extent as refugees. The 5-year bar does not apply. 7-year eligibility limits do not apply.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |61 Effective Month: July 2025 OVERVIEW OF ALIEN ELIGIBILITY FOR MEDICAID If ineligible for ongoing Medicaid, the individual may be eligible for full benefits for 8 months beginning with date of entry through the Refugee Resettlement Grant. 102.06 SOCIAL SECURITY NUMBER (SSN) Enumeration is the process of assigning Social Security Numbers. In general, applicants for Medicaid must be enumerated as a condition of eligibility by either • Furnishing their Social Security Number - The applicant can verbally provide the SSN when they do not have a card or other document with the number on it; or • Providing verification of an application for a Social Security Number when a number has not already been assigned. Assistance cannot be denied, delayed or discontinued if the applicant, beneficiary or his representative cooperates in providing the SSN of the applicant or applying for the applicant’s number. However, if the applicant/beneficiary or his representative refuses to disclose a valid number for the applicant or refuses to apply for the applicant’s number, the applicant’s or recipient’s eligibility will be denied or terminated.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |62 Effective Month: July 2025 102.06.01 EXCEPTIONS TO THE ENUMERATION REQUIREMENT FOR APPLICANTS Exceptions to the enumeration requirement for Medicaid applicants are limited to the following: • Non-qualified aliens applying for Emergency Medicaid services only do not have to provide a Social Security Number or provide proof of an application for a number as a condition of eligibility. • The Social Security Administration (SSA) does not issue SSN’s to deceased individuals. The enumeration requirement is applicable if the SSN was issued prior to death. • The enumeration requirement may be waived for an applicant who, because of well-established religious objections, refuses to obtain a Social Security Number: o A well-established religious objection means that the individual is a member of a recognized religious sect or division of the sect and adheres to the tenets or teachings of the sect and for that reason is conscientiously opposed to applying for or using a national identification number. o A written statement must be obtained that includes the religious affiliation and reasons for objecting the SSN requirement. Forward all documentation to the central office for a final decision. • Individuals not eligible to receive a SSN, such as an alien illegally residing in the U. S. • An individual who does not have a SSN and may only be issued one for a valid non-work reason. These are aliens currently in a lawful immigration status in the U. S. that do not have Department of Homeland Security work authorization. NOTE: The SSN requirement is postponed for deemed eligible infants until the first redetermination. 102.06.02 NON-APPLICANTS AND ENUMERATION Non-applicants for MAGI and Medicare Cost Sharing COEs cannot be required to disclose their own SSN as a condition of eligibility. For example, a mother who is applying for Medicaid only for her children cannot be required to provide her SSN. even though she has financial responsibility for the children.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |63 Effective Month: September 2018 Medicaid Specialists should explain that the voluntary disclosure of the SSN will enable the agency to make a more accurate eligibility determination and ensure correct benefits. The application for MAGI or Medicare Cost Sharing must not be denied solely because a non-applicant’s SSN is not disclosed. If the non-applicant’s income is countable in the budget and is from a source usually verified using the SSN, alternate verification will have to be provided. Non-applicants whose assets would count in the applicant’s budget are required to provide their social security number for asset tested ABD COEs. 102.06.03 USE OF SSN’s SSN’s will be matched with state and federal agencies specified in Chapter 101, Section 101.08.03A, Electronic Data Sources Utilized by DOM. Data matches with state and federal agencies occur at the time of application for the purpose of verifying U.S. citizenship or qualified alien status and at application and renewal for the purpose of verifying certain types of income and resources. PARIS matches to identify duplicate participation occur quarterly for active recipients. Match data must be evaluated by the Specialist in a timely manner, i.e., within 10-days of receipt of the data, to determine what action is needed. Match data may result in no action needed, or the need for independent verification of the data or result in an adverse action needed, depending on the data source and the information reported. The agency has permission to obtain match data based on signed and dated application and/or renewal forms that provide an explanation of how SSN’s will be used for matching purposes to determine eligibility. 102.06.04 APPLICATION FOR A SOCIAL SECURITY NUMBER When an applicant has not been enumerated, two methods may be used to obtain an SSN. The methods are: • Application Filed at the Social Security Office: The applicant/beneficiary completes a Form SS-5, Application for Social Security Card, and mails or takes the original SS-5 with required documentation to the SSA office. The applicant/beneficiary then must provide DOM with an official receipt from SSA to meet the requirement of applying for a SSN. A copy of the receipt must be filed in the case record.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |64 Effective Month: September 2018 • Enumeration at Birth: A parent gives permission on the birth certificate registration form for the Bureau of Vital Statistics to provide a child’s birth information to SSA to assign a Social Security Number to the child. When a Medicaid application is filed for a newborn, not deemed eligible, the parent must either provide the child’s Social Security Number or provide verification that an application has been filed through the enumeration at birth process or directly with SSA. Enumeration can be verified by the newborn’s birth certificate which verifies enumeration at birth or by a document from SSA such as the SSA-2853, A Message from Social Security, or SSA-5028, Application for a Social Security Number, which confirms the SS-5 was filed. When these verification methods are used, the SSN must be provided at the next annual review. 102.06.05 VERIFICATION OF THE SSN When the applicant provides a document with the SSN or provides the number verbally, the Medicaid Specialist must enter the SSN in MEDS and select “Hub verification” so that the SSN can be verified with SSA to ensure the SSN was issued to that individual and to determine whether any other SSN’s were issued to that individual. The Federal Data Services Hub or SVES verifies SSN’s. If the FDSH verifies the SSN belongs to the individual, a MEDS entry of “verified” will be entered automatically. If the SSN is not verified, the specialist must resolve any discrepancies, such as incorrect entry of the SSN. Upon correcting the SSN, verification from the FDSH will occur in real time. An applicant should be referred to SSA to resolve issues with a name/SSN mismatch. The SSN must be verified prior to approving eligibility unless SSA confirms the correct SSN by direct contact or confirms the amount of time needed to resolve the matter. Multiple SSN’s in Different Names Individuals may have multiple SSN’s assigned based on evidence documenting harassment, abuse or life endangerment or for other specific reasons allowed by SSA. When SSA assigns a new SSN for one of their acceptable reasons, the old and new SSN’s are cross-referenced. If an applicant has more than one SSN and the SSN’s are not cross-referenced, there must be a determination made by SSA if the SSN’s actually belong to the individual. Refer the individual to SSA to resolve the issue and request that the individual return with documentation from SSA as to the outcome.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |65 Effective Month: September 2018 102.07 CATEGORICAL ELIGIBILITY Eligibility for the Medicaid program is limited to certain groups of individuals authorized by Congress. When authorizing a group, Congress also establishes specific requirements which must be met to qualify as a member of that group. Each designated group is assigned a category of assistance. The requirements which must be met to fit into a group or category are known as categorical requirements. The Division of Medicaid is responsible for the following categories of assistance as specified in Chapter 101, Section 101.02, Coverage of the Categorically Needy in Mississippi: • Aged, • Blind, • Disabled, • Children under age 19, • Pregnant women, • Low-income parent(s) or caretaker relatives of dependent children (under 18). • Former foster children to age 26 (in the event the foster child’s eligibility is not enabled systematically). Aged An individual categorically eligible as aged must be 65 years of age or older. According to SSI policy, a given age is attained on the first moment of the day preceding the anniversary of the individual’s birth. Example: A person born on January 1, 1943, is considered to be age 65 as of December 31, 2007, and meets the definition of an aged individual in the month of December 2007. A person born January 2, 1943, meets the definition of an aged individual in January 2008. Blindness and Disability To be categorically eligible for Medicaid as blind or disabled, the individual must, at a minimum, meet the Supplemental Security Income (SSI) definition of blindness or disability. The Disability Determination Service (DDS) makes all decisions relating to disability and blindness for the Division of Medicaid and the Social Security Administration (SSA).

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |66 Effective Month: July 2025 Children under Age 19 Effective 01/01/2014, MAGI-related programs serve children under age 19 in specific age groups under specified levels of poverty. Prior to 01/01/2014, MAGI programs were referred to as programs for families and children and CHIP. Children have continuous eligibility for a 12-month certification period unless an “early- out” termination reason is met. Pregnant Women A pregnant woman of any age is categorically eligible. A pregnant woman’s eligibility includes a 12-month post-partum period following the month of delivery, miscarriage or other termination of pregnancy. Effective 01/01/2014, self-attestation of pregnancy, due date and number of babies expected is accepted. Verification of pregnancy may only be required if information available to the agency, such as claims data, is found to conflict with the individual’s self-attestation regarding pregnancy. Low Income Parent(s) or Caretaker Relatives of Dependent Children (under age 18) Effective 01/01/2014, low-income parent(s) or caretaker relatives of children under age 18 are categorically eligible for Medicaid as a stand-alone group. This includes households with a single parent or 2-parents or a caretaker relative and his/her spouse, if living together. Prior to 01/01/2014, low-income families were covered that included parent(s) or caretaker relatives and dependent children under age 18. Children’s coverage was separated from adult coverage effective 01/01/2014. A low-income pregnant woman with no other children in the home may qualify as a low-income parent. She is assessed for eligibility as if her unborn child were born. If there is a spouse, the spouse’s eligibility for MAGI-related coverage cannot be assessed until the child is born; however, the spouse’s needs, and income are included for pregnant spouse’s eligibility.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |67 Effective Month: July 2025 102.08 GENERAL ELIGIBILITY REQUIREMENTS The eligibility requirements common to both ABD and MAGI are discussed in this section. When the requirement also has a program-specific application, it is discussed separately with ABD discussed first, then MAGI. Basic Eligibility Requirements An eligible individual must be in one of the categories of assistance discussed in 102.07; and, • Meet all non-financial factors of eligibility discussed in this chapter, such as state residency, citizenship or alienage, etc. • Have income and resources, when applicable, within specified program limits; and, • File an application. Reasons for Ineligibility Notwithstanding the above, an individual is not eligible in any program if the person: (1) Fails to assign rights to any third-party medical support or cooperate with Medicaid in obtaining third party payments. (102.08.05) (2) Is a resident of a public institution age 21 or over. (102.12) Eligible Individuals Aged, Blind and Disabled Programs The eligible ABD adult or child is one who meets all basic program requirements. An eligible spouse is a person who (1) meets all of the basic program requirements, (2) is the husband or wife of an eligible individual and (3) lives with the eligible individual. This includes a man and woman who hold themselves out as husband and wife. The individual and spouse must each apply and meet all of the basic program requirements to establish eligibility as a couple.

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |68 Effective Month: September 2018 MAGI-Related Programs Children under age 19, pregnant women of any age and parents or needy caretakers, within the specified degree of relationship, are eligible individuals for MAGI-related eligibility if they apply and meet program requirements. Parents may be married or unmarried. Effective 01/01/2014, parents include the biological, adopted or stepparent of a child and siblings include biological, adopted or stepsiblings within a household or budget group. Prior to 01/01/2014, stepparents were not considered legally responsible for a stepchild. A caretaker relative is related by blood, adoption or marriage with whom the dependent child is living, who assumes primary responsibility for the child’s care, as may be indicated by claiming the child as a tax dependent for federal income tax purposes and meets a specified degree of relationship, as specified in 102.11.03. The caretaker relative’s spouse is also covered if living together and otherwise eligible. A dependent child is under the age of 18 and is deprived of parental support by reason of death, absence from the home, physical or mental incapacity, or unemployment (or underemployment) of at least one parent. Deprivation is outlined in 102.11.01 and is relevant to the eligibility of the parent/caretaker and not the child. 102.08.01 VERIFICATION OF AGE The age of an individual must be verified in the following situations: • The applicant is an adult or child applying for benefits which are based on age; • There are ineligible children in an ABD deeming household; • A disabled or blind applicant under age 21 applies for ABD and any of the following conditions exist: o Deeming o Student earned income exclusion o Support from absent parent exclusion

MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |69 Effective Month: September 2018 The primary source for age verification is electronic data sources. • SSA is the primary electronic data source to verify the age of an individual. SSA records includes: o SSA Composite Data, o SVES, o BENDEX Data o SDX Data • EVVE birth verification provided the place of birth is a state participating in EVVE. • Department of Homeland Security provided through the SAVE process as outlined in 102.05.02. Requiring paper documentation to resolve age discrepancies should be rare and is only required if eligibility is affected. If paper verification is required, the following are acceptable sources of age verification: • Birth certificate or other birth records - (Must be established during the first 5 years of life and certified by the custodian of the record. This could include a statement signed by the midwife or physician who was in attendance at the birth and who attests to the date of birth.) • Religious records - Family Bible or other family record – must examine the entire publication Baptismal or confirmation certificate • Hospital, school or physician/clinic records • State or Federal Census records established near date of birth • Marriage record which shows age or date of birth • Insurance policy which shows age or date of birth • Passport • Employment records • Military records • Child’s birth certificate which shows parent’s age Records which might be available to those born in foreign countries that are in an alien status that is not verified through SAVE includes the documents listed above and the following: • Foreign passport • Immigration record established upon arrival in the U. S. • Naturalization papers – if used to verify citizenship • Alien registration card