2052 Continuing Medicaid Determination | Medicaid

Georgia Division of Family and Children Services
Medicaid Policy Manual

Policy Title:

Continuing Medicaid Determination

Effective Date:

July 2023

Chapter:

2050

Policy Number:

2052

Previous Policy Number(s):

MT 69

Updated or Reviewed in MT:

MT-70

Requirements

Eligibility must be reviewed under all Medicaid Classes of Assistance (COAs) before denying a Medical Assistance application or an individual in a Medicaid Assistance Unit (AU), and prior to termination of ongoing Medicaid eligibility for an entire AU or individual in an AU. For individuals who have been terminated SSI, DFCS will redetermine their Medicaid eligibility prior to DCH terminating their Supplemental Security Income (SSI) Medicaid.

Basic Considerations

Do not deny or terminate Medicaid eligibility before completing a Continuing Medicaid Determination (CMD) to consider eligibility under all other Medicaid COAs.

Complete a CMD on all SSI terminations that appear on DCH generated reports or transmitted via the Ex-Parte interface. Refer to 2750 DCH Reports-Ex Parte Lists for processing instructions.

If the MES becomes aware of A/Rs who, because of an SSI denial/termination, have been inappropriately receiving Medicaid under an Ex Parte COA, follow the same instruction found in 2750 DCH Reports-Ex Parte Lists.

Process the CMD according to which COA is most advantageous to the applicant/recipient (A/R).

Any Medicaid application form may be used to consider eligibility under any Medicaid COA. However, additional requirements may need to be satisfied depending on the specific COA under consideration. EXAMPLE: A Form 700 used for another ABD COA may require verification. Refer to 2060 ABD Medicaid Application Processing and 2065 Family Medicaid Application Processing for acceptable application forms.

ABD Medicaid

For ABD Medicaid, consider eligibility under all COAs in the following order:

FBR COAs
LA-D/Medicaid CAP COAs
Q-Track COAs

AMN

Q-Track COAs may be approved while the A/R is waiting to meet an ABD Medically Needy spenddown. Refer Medicare recipients to Georgia SHIP (formerly known as GeorgiaCares) for help with applying for Medicare Part D. See 2931 Medicare Part D and Low-Income Subsidy.

QI-1 recipients cannot be dually eligible ongoing with another COA with exception of AMN.

Family Medicaid

For Family Medicaid, consider eligibility in the following order:

Newborn
Pregnant Women
Parent/Caretaker
Other Family Medicaid COAs based on Parent/Caretaker eligibility criteria, i.e., TMA, 4MEx
Children Under 19
PeachCare for Kids®
Family Medicaid Medically Needy
Women’s Health Medicaid (WHM)
Pathways

Planning for Health Babies®

If all verification requirements are met for Pregnant Women and/or Children Under 19, eligibility may be approved for either of these COAs while eligibility is being determined under Parent/Caretaker.

Medicaid eligibility for a child in foster care is determined first under the IV-E FC program. If ineligible under the IV-E FC program, Medicaid eligibility is determined under CWFC Medicaid.

Chafee Independence Program Medicaid

Reference 2818 Chafee Independence Program Medicaid for eligibility criteria and procedures for Revenue Maximization, RSM Project and county offices.

CMD Application Requirements

A new application is not required at CMD when eligibility for a COA is terminated, and previously eligible AU members are subsequently approved for another COA.

A new application is not required if the previously eligible AU received a Q-track Medicaid COA based on an original application filed using Form DCH 700.

A new application is not required while completing a CMD for an AU member that is going to a higher or lower COA. For Family Medicaid, if the existing AU has trickled to a lower COA, a new application is required in order to process a CMD to a higher COA (such as from Children under 19 to Parent/Caretaker) if you are adding an existing BG member or new individual to the AU. If a CMD is processed to a higher COA, and all of the existing AU members are still covered (such as from TMA to Parent/Caretaker) a new application is not required. Refer to 2065 Family Medicaid Application Processing.

A new application is never required when approving Newborn Medicaid COA.

CMD Interview Requirements

An interview is not required as part of the CMD process, including when adding an individual to an existing AU and when a new individual is included in the approval of a new COA as part of the CMD process. It may be necessary, however, to contact the AU by telephone, by mail or in person if the new COA requires information not included at the time of application for the terminated COA.

Procedures

ABD and Family Medicaid

Follow the steps below to complete a CMD for an ABD or Family Medicaid denial or termination:

Step 1	Consider eligibility under all COAs (both ABD and Family Medicaid) prior to denial or termination of Medicaid.
Step 2	Approve Medicaid under the COA that will provide the most medical coverage if the A/R meets all eligibility requirements for the COA.
Step 3	Deny or terminate Medicaid if the A/R does not meet the requirements for any Medicaid COA.
Step 4	Notify the A/R of his/her Medicaid eligibility as follows: Send adequate notice when completing the CMD on an application or changing COAs for a current Medicaid recipient Send timely notice if the CMD results in termination of Medicaid eligibility or the reduction of Medicaid benefits for a current recipient.

When completing CMD from Parent/Caretaker to TMA or 4MEX, timely notice is required.

SSI Terminations

Federal Law mandates that a CMD be completed on all SSI terminations before Medicaid can be terminated by DCH. As part of this CMD process, DCH will determine if continued eligibility:

should exist under SSA Section 1619(a) or (b) Work Incentives and, therefore, should be referred to SSA (See 2579 SSI 1619 Individuals);

OR
exists under another Medicaid coverage group and switch the individual to this new Medicaid coverage group.

As part of the automated Ex-Parte process, reports listing the names of individuals who have been converted to a new coverage group will be generated and received via Gateway. Refer to 2750 DCH Reports-Ex Parte Lists for specific instructions on how to complete the CMD process for an A/R terminated from SSI.

The Personal Responsibility and Work Opportunity Act of 1996, commonly referred to as the Welfare Reform Act, specifically prohibits individuals wanted in connection with a felony or in violation of the terms of their parole or probation or an outstanding warrant, from receiving SSI, Food Stamps, TANF benefits, and federal housing assistance. There is no prohibition written into federal law that prohibits these so called “fugitives” from receiving Medicaid. If someone is terminated from SSI due to their “fugitive” status Medicaid cannot be denied for the same reason. The fugitive could still be eligible for Medicaid provided he/she meets the requirements for some other group covered under the State’s Medicaid plan, such as the Adult Medically Needy program.