Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 20 - Division of County Operations
Rule 016.20.97-025 - Medical Services Policy Manual - Revised Policy

1. The alien has a medical condition (including labor and delivery) 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:

. Placing the patient's health in serious jeopardy,

. Serious impairment to bodily functions, or

. Serious dysfunction of any bodily organ or part.

2. To be eligible for emergency services, an alien meeting the medical criteria in paragraph 1 also must meet all other eligibility requirements for Medicaid (categorical, income, resources, etc.) as set forth in the State's approved plan, with the exception of citizenship/alienage requirements, and Social Security enumeration.

Verification and documentation of the emergency condition must be obtained through the attending physician's statement that the alien met the criteria in paragraph 2. In addition, the alien will provide other supporting documentation of the emergency that may include hospital and emergency room records, ambulance receipts, collateral statements, media reports, etc.

If certified in a family type Medicaid category, only the alien(s) with the emergency medical condition(s) may be entered in closed status for fixed eligibilty as an eligible member(s); all other citizen or qualified alien family members included in the budget will be entered in closed status with no medical eligibility.

NOTE: When determining eligibility for an adult, deem the income of a non-qualified alien spouse to the applicant, but do not include his or her needs in the need standard. A citizen or qualified alien spouse's income must be counted in full, with his or her needs included. The income and needs of non-qualified alien children will be disregarded. A citizen or qualified alien child's income and needs may be included if needed.

When determining eligibility for a child, deem the income of a nonqualified alien parent(s) to the applicant, but do not include needs of the parent(s) in the need standard. Income of a citizen or qualified alien parent(s) m"st be counted in full, with the needs included. The income and needs of non-qualified alien siblings will be disregarded. A citizen or qualified alien sibling's income and needs may be included if needed.

A period of eligibility will be granted only to cover the period of time in which the necessity for emergency services existed. The period of eligibility will be a fixed retroactive period, and Medicaid begin and end dates will be entered.

The certified alien(s) will be eligible for all medical services relating to the emergency, including transportation.

1. received services in the retroactive period; and

2. were eligible in the month the services were received.

Retroactive eligibility will be provided to applicants who were otherwise eligible in the month services were received, regardless of whether they were ineligible at other times during the retroactive period. Retroactive eligibility is separate and apart from current eligibility, i.e., applicants not eligible for the current period may be eligible for the retroactive period. Retroactive eligibility determinations are required for all categories, except AAS/ACS, DDS/ACS, QMB, SMB, QDWI, and PW-PE Retroactive coverage for Newborns will not be given prior to the date of birth.

An application for retroactive eligibility may be made on behalf of deceased persons and eligibility will be provided if they were eligible when the services were received.

For cases in which an applicant has not resided in Arkansas for three full months prior to the date of application, the retroactive period begins with the date the individual established residency in Arkansas. The "previous state" is responsible for the retroactive period prior to the time the applicant established residency in Arkansas. The County Office is responsible for providing the "previous state" with information necessary to determine eligibility for its portion of the retroactive period.

Services for the retroactive period are subject to the same restrictions as services, for the current period (i.e., utilization review, benefit limitations, medical necessity, etc.). Prior authorization cannot be a condition of payment for services received during the retroactive period. However, such services are subject to the same Title XIX Utilization Review standards as all other services financed under the State's

Title XIX program. The State is not required nor obligated to pay for services which have been retroactively determined by Utilization Review to be unnecessary.

1. the services were necessary and the applicant was eligible when the services were received; and

2. Medical necessity (Re. 3350).

The case record must document that both these requirements have been met before facility services can be authorized.

1. Institutional Status - It must be verified that the individual has been institutionalized for 30 consecutive calendar days (an exception to the 30 days is made when death occurs prior to 30 days). Re. MS 3320. The period of 30 days is defined as being from 12:01 a.m. of the day of admission to 12:00 midnight of the 30th day following admission. For example, an individual enters a facility anytime on July 18th. The 30 day count begins at 12:01 a.m. of the morning of July 18th, and ends at midnight of August 16th. Hospitalization will count toward meeting the institutional status requirement if the individual enters a facility on the date of discharge from the hospital. This includes hospitalization at Arkansas State Hospital in Little Rock, and the George W. Jackson Center in Jonesboro.. It also applies to individuals who enter an Arkansas institution directly from an out-of-state institution;

2. Categorical Relatedness - In order to meet the requirement of categorical relatedness, the individual must meet one of the following:

3. Citizenship or Alien Status (Re. MS 3324) - Under the provisions of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.L. 104-193), enacted August 22, 1996; and the Balanced Budget Reconciliation Act of 1997 (P.L. 105-32), enacted August 5, 1997; Medicaid eligibility will be granted only to an individual who is documented and found eligible as one of the following:

4. Residency - It must be verified that the individual is an Arkansas resident (Re. MS 2200);

5. Resources - Countable resources cannot exceed $2000 for an individual and $3000 for a couple.

NOTE: The resource standards above apply to all AABD Medicaid categories (the resource standards are doubled for QMBs, SMBs, and QDWIs), except when one spouse enters LTC and the other does not (Re. MS 3337-3338) or when both spouses enter LTC in the same month. When both spouses enter LTC in the same month, the couple's standard will apply for the month of entry, but the resources of each will be compared to the individual standard in the month after entry into LTC (Re. MS 3330.1);

6. Income - The individual's gross income cannot exceed the maximum income limit allowed for federal financial participation. The income limit for LTC is three times the SSI payment standard. However, individuals with income over the limit may be eligible if they have established an income trust (Re. MS 3336.9);

7 Assignment of Medical Support (Re. MS 1350);

8. Cooperation with Child Support Enforcement Activities (Re. MS 1310); and

9. Social Security Enumeration (Re. MS 1390).

1. Receipt of SSI (AB or AD), or receipt of a letter of entitlement to SSI with begin date of entitlement, when the individual has not received the first check. Verify by SSI Award Letter, SSA-1610, "SSI Recipients" printout, or WTPY Response;

2. Receipt of Social Security based on disability, or receipt of a letter of entitlement to Social Security based on disability, showing a begin date of entitlement, when the individual has not received the first check. Verify by SSA Award Letter, SSA-1610, or WTPY Response;

3. Receipt (or anticipation) of SSI or Social Security Disability based on a disability benefit continuation, when an individual has requested continuation within 10 days of SSA determination that a physical or mental impairment has ceased, has not existed, or is no longer disabling;

4. Nonreceipt of SSI cash benefits for reasons other than disability, but verification of an established disability that is current and continuing; e.g. TEFRA child (Re. 2090); or

5. Blindness or Disability determination by the Medical Review Team. The DCO-109 (Report of Medical Review Team decision) must be filed in the record.

The type of documentation used will be entered into the case narrative and a copy filed in the case records, if available.

3322.1 SSA vs. MRT Disability Decisions

The following disability guidelines will apply to all AD Medicaid applicants where disability is an eligibility factor and disability has not been determined. A disability decision made by SSA on a specific disability is controlling for that disability until the decision is changed by SSA. When DCO makes a disability determination, a later contrary SSA determination will supersede the state determination. If SSA has made a decision that a person is not disabled, that decision is binding on DCO for one year with exceptions noted in 3322.3.

3322.2 Referrals to SSA

Because SSA decisions are controlling, any new evidence or allegations relating to previous SSA determinations must be presented to SSA for reconsideration within 60 days of the SSA denial notice. If the decision has not been appealed within 60 days, the ' individual may still request a reopening of the decision within one year.

v" Therefore, the Agency must refer to SSA, for reconsideration or reopening of a determination, all applicants who allege new information or evidence which affects previous SSA determinations of "not disabled", except in cases specified in 3322.3. When the conditions in 3322.3 are met, counties will be required to make an eligibility determination for Medicaid.

Counties may also refer to SSA, for SSI application, those individuals whose income and resources are below SSI limits, because it would be to their advantage to receive both cash assistance and Medicaid.

3322.3 Applications Which Will Require An MRT Decision

When individuals apply for Medicaid and meet one or more of the conditions below, the DCO-106, DCO-107's and/or DHS-81's, and DCO-108, along with copies of the Social Security Disability or SSI denial letter (if applicable and available) and WTPY, if appropriate, will be submitted to MRT (Re. MS 3323), provided it appears that the other eligibility factors are met.

The Agency will determine eligibility if any one of the following conditions exists:

3322.4 Verification of Social Security Disability or SSI Status

, To verify the Social Security Disability or SSI status of an individual the county will:

3322.5 Dual Applications

When an individual applies for both Medicaid and Social Security Disability or SSI, and the application with SSA is still pending, the county should initiate an MRT determination of disability if the individual appears to meet all other eligibility requirements. The Agency will have 90 days from the date of Medicaid application to make this determination. While an MRT decision is pending, the county office worker should check the Social Security Disability or SSI status of the applicant 30 days after the Medicaid application has been made, and again at certification, if found eligible by MRT. If MRT finds that the individual meets the disability requirements and SSA has not yet made a decision, the county may certify the case for Medicaid. To verify that no SSA decision has been made, the WASM screen will be checked, if appropriate, and the individual or authorized representative will be contacted by mail or telephone prior to certification.

Additional case action is indicated as follows:

If application for Social Security Disability is approved first:

. Notify MRT

Approve Medicaid application (if all other requirements have been met)

If application for SSI is approved first:

. Notify MRT

Deny Medicaid application, except for LTC, which may be approved for facility payment on WNHU (if all other requirements have been met)

If SSA determines the applicant is NOT disabled:

. Notify MRT

Deny Medicaid application

If the county certifies a case based on an MRT disability decision and later learns the individual has been denied by SSA, the Medicaid case will be closed after appropriate notice, unless theVecipient appeals the closure. If the appeal is made within the 10-day time frame, the Medicaid case will remain open pending the outcome of the DHS appeals process. In no case, will the Medicaid case remain open pending the outcome of the SSA appeals process if the recipient has appealed the SSA decision. If an approved Medicaid recipient is approved for SSI, the system will automatically convert the Medicaid case to an SSI category and no further action will be required of the county, except to notify MRT that no future reexamination is required, if appropriate.

3323.1 For Blindness

3323.2 For Disability

3323.3 Medical Review Team (MRT) Decision

The Medical Review Team (MRT) will report the decision regarding physical or mental incapacity to the county office on Form DCO-109.

If MRT finds that the medical information is not adequate to make a decision, further medical/psychiatric/psychological examinations may be recommended by MRT at the expense of the Agency.

Arrangements for such evaluations will be made by MRT only. When medical and social evidence has been resubmitted on questioned cases, the Medical Review Team will make a decision as to disability and notify the county office on Form DCO-109. This decision of MRT will be final, subject to the regular appeal process, unless a later decision by SSA finds the individual not disabled.

3323.4 Reapplication Due to Mental or Physical Incapacity

If a reappl ication is filed and the case has been closed within the past five years for reasons other than disability and the last Form DCO-109 stated, "Re- examination not necessary" or the date for reexamination has not yet been reached, new medical and social information will not be submitted to MRT. If the case has been closed for more than five years, new medical and social information must be submitted. In all cases of reapplication, a DCO-106 will be completed to determine the applicant's SSA disability status.

3323.5 Reexamination of Disability by the Medical Review Team (MRT)

When medical and social information indicates that an individual may recover in a year or more and/or be rehabilitated to the point where he could meet substantial gainful employment, the MRT will require reexamination. Whether or not required by MRT, reexamination may be requested by the county office at any time for the aforementioned reasons.

In either case, it is the responsibility of the county office to initiate the reexam by submitting current medical and social information (DCO-106, DC0-108A, and DCO-107 and/or DHS-81) to MRT.

3323.6 Reexamination Required by the Medical Review Team (MRT)

When indicated on the DCO-109, the county office will key the appropriate date to WALR for future action. The county office will contact the individual in a timely manner that will allow all necessary medical and social information to reach MRT by the first of the month of reexamination. When the reexamination decision is not received in the county office by the end of month in which the reexamination was required, the case will remain open pending receipt of the MRT decision.

3323.7 Reexamination Resulting from Substantial Gainful Activity

Substantial gainful activity (SGA) is defined as the performance of significant physical and/or mental work activities for pay or profit, or in work activities generally performed for pay or profit.

Countable monthly earnings are obtained by deducting any employer subsidy and any impairment related work expense (not payroll deducts) from the gross income (gross income includes payment in-kind for the performance of work in lieu of cash). Then, if earnings are irregular, they will be averaged over the period of months being considered to obtain countable monthly earnings.

Employer subsidy is the payment of wages that is more than the value of the actual

' services performed.

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"If the work is sheltered or if there is marked discrepancy between the amount of pay and the value of services, there exists the strong possibility of a subsidy that requires development of specific evidence.

Sheltered Employment is work performed by handicapped individuals in a protected environment under an institutional program; nonsheltered employment is any work performed by individuals in an unprotected environment.

Impairment Related Work Expenses are items or services needed in order to maintain employment, such as attendant services, prostheses, or other devices. Drugs and medical services are not deductible unless it can be shown they are necessary to control the disability to enable the individual to work. Deductible expenses must be paid for by the individual, and cannot be reimbursable from any source. Legitimate expenses may include installation, repair, or maintenance; the payments may be deducted in one month or prorated over 12 months.

The expenses must be considered "reasonable," i.e. not more than Medicare would allow or than would ordinarily be charged in the individual's community.

The following SGA Earnings Guidelines provide the basis for evaluating whether an individual is engaged in SGA:

1. Methods of Verifying Citizenship - Citizenship may be verified by any document which shows the place of birth. One document is sufficient. A copy of the document used to verify citizenship will be retained in the case record. The document may be the same as that used to verify the date of birth. Acceptable evidence of citizenship include:

2. Methods of Verifying Alien Status - Verification needed to establish alien status is as follows:

3. Deeming of Income - In determining eligibility for LAPRs, parolees, and conditional entrants after the five year ban expires, the income and resources of the alien's sponsor and the sponsor's spouse must be considered as fully available to the alien and his or her family when the sponsor has executed a new legally binding affidavit of support.

Deeming applies only to immigrants who are sponsored by individuals. Deeming will not apply to battered immigrants or to those who would be indigent (unable to obtain food and shelter without assistance) because their sponsors are not providing adequate support.

4. Medicaid Eligibility for Terminated SSI Recipients - The alienage requirements of P.L. 104-193 are somewhat different for SSI than for Medicaid. Medicaid has some options under the law that are not allowed for SSI.

The only aliens qualified to receive SSI are refugees, asylees, and noncitizens whose deportation has been withheld (subject to a five year eligibility limit); honorably discharged veterans, active duty armed forces personnel, their spouses and dependent children; and lawfully admitted aliens who have 40 qualifying work quarters for SSA purposes.

The Social Security Administration (SSA) sent active SSI beneficiaries notice in February and March 1997, to advise them that SSA will be reviewing their citizenship or immigrant status. If the recipients were not in one of the eligibility categories, they received a second notice after a period of 90 days telling them that their benefits were terminated. If recipients appeal this action by SSA, their benefits can continue during their appeal.

If an individual whose SSI benefits and Medicaid have been terminated by SSA comes to a county office to apply, the county must look at all Medicaid categories to determine if the individual would qualify (e.g., QMB, SMB, Medically Needy, ElderChoices, etc.). If the individual can meet the alienage requirements along with the other eligibility requirements for a chosen category, the individual may be certified in that category.

3324.1 Declaration of Citizenship or Satisfactory Immigration Status

The Immigration Reform and Control Act (IRCA) of 1986 ( P.L. 99-603) requires that, as a condition of an individual's Medicaid eligibility, the individual must declare in writing under penalty of perjury if he or she is a citizen or national of the United States or, if not, that he or she is an alien in satisfactory immigration status. This requirement does not affect the existing citizenship and alienage requirement nor does it affect the verification requirements for citizenship or alienage. Therefore, an allegation of U.S. citizenship must still be verified, and the immigration status of all aliens must be verified.

Each adult applying for or receiving Medicaid assistance must make his or her own declaration of citizenship or satisfactory immigration status. The parent or guardian will make the declaration for all unemancipated persons under the age of 18 or otherwise incapacitated for whom medical assistance is requested. A legal guardian may also make the declaration for minors or for individuals otherwise incapacitated.

The application form will serve as the written declaration of citizenship for the applicant and/or any unemancipated persons under the age of 18. Caseworkers should be alert to the proper completion of the question on the application regarding citizenship for each person. As the declaration of citizenship is an eligibility requirement for the individual, the citizenship question on the application form must be answered for each person who will be an eligible in a Medicaid case.

In LTC cases where the applicant/recipient or the applicant/recipient's legal guardian has completed a DCO-777, no further action is necessary. In instances where an authorized representative other than a legal guardian has signed the DCO-777, the applicant/recipient should sign the DCO-9, unless he or she is physically or mentally incompetent to do so. If the applicant/recipient is unable to sign the DCO-9, then the authorized representative's declaration on the DCO-777 will be accepted as declaration of citizenship.

Once an adult has provided declaration of citizenship or satisfactory immigration status for himself or herself or others, a declaration will not be required again unless an individual loses eligibility. If the individual later reapplies, a new declaration will be obtained. -