Arkansas Administrative Code, Division 20, Rule 016.20.98-029 - MS 98-5: SOBRA Medicaid Coverage of Pregnant Woman, Infants and Children - Revised Policy - Expand Medicaid coverage to children born after September 30, 1982, and before October 1, 1983, whose family income is at or below 100% of the Federal Poverty Level. | Arkansas Administrative Code

2000 Individuals Eligible for Medicaid

The following categories of Individuals are eligible for Medicaid:

1. Individuals eligible for Supplemental Security Income (SSI) benefits (i.e., recipients of straight SSI benefits, mandatory state supplements, SSI conditional payments and SSI presumptive disability payments). Re. MS 2010;

2. Blind or disabled individuals with converted cases who are not considered to be blind or disabled under SSI criteria. Re. MS 2020;

3. Individuals eligible for Medicaid as essential spouses in December 1973 and who continue to meet that eligibility criteria. Re. MS 2025;

4. Medical Only Individuals who are current recipients of SSA; who were previously eligible for and received SSA and SSI concurrently in at least one month after April 1977; and who would now be eligible for SSI if all COLA increases received since they last received SSA and SSI concurrently were deducted from current income. Re. MS 2030;

5. Medical Only Individuals whose assistance payments were terminated due to the 20% increase in Social Security benefits in September 1972, and who would be currently eligible for assistance payments if the 20% increase in Social Security benefits in September 1972 were disregarded. Re. MS 2040;

6. Disabled widows and widowers who were entitled to SSA for December 1983; who received SSA disability for January 1984; who lost SSI after January 1984, due to elimination of a benefit reduction factor previously applied; who would be SSI eligible if the 1984 reduction factor increase and all COLA's since 1984 were disregarded; and who applied and were found eligible for Medicaid benefits between July 1, 1986, and June 30, 1988. Re. MS 2045;

7. Disabled widows and widowers who were at least age 60 on or after 4/1/88, were not yet age 65 on 4/1/88, formerly received SSI benefits which were terminated due to entitlement to SSA widow's or widower's benefits, currently receive SSA widow's or widower's benefits, are not currently eligible for Medicare, would be eligible for SSI if ALL SSA benefits were disregarded, and are otherwise income and resource eligible for Medicaid. Re. MS 2046;

8. Disabled widows, widowers and disabled surviving divorced spouses who lost their SSI due to receipt of SSA benefits based on a less restrictive definition of disability that was used prior to OBRA of 1990. Re. MS 2049;

9. Qualified Medicare Beneficiaries who qualify under the Medicare Catastrophic Coverage Act of 1988, and whose benefits are limited to Medicare cost-sharing. Re. MS 2047;

10. Specified Low Income Medicare Beneficiaries whose income is between 100% and 120% of the Federal Poverty Level and who meet all other requirements for the Category will be eligible for payment of their Medicare Part B Premium. Re. MS 2051;

11. Qualified Disabled and Working Individuals who lost Medicare Part A entitlement solely due to Substantial Gainful Activity. Medicaid coverage for these individuals is limited to payment of their Part A premium. Re. MS 2048;

12. Disabled Adult Children (DAC) who are age 18 or older, who became disabled or blind before age 22, who were receiving SSI based on disability or blindness, and who lost SSI on or after July 1, 1987 due to a DAC entitlement or a DAC increase. Re. MS 2050;

13. Individuals who were eligible for Medicaid in Title XIX institutions in December 1973. Re. MS 2044.3;

14. Families who lose TEA related Medicaid eligibility due to increased wages and who qualify for up to 12 months of transitional Medicaid. Re. MS 2061;

15. Families who lose TEA related Medicaid eligibility due to collection of child support payments and who qualify for up to 3 months of extended Medicaid. Re. MS 2063;

16. Eligible individuals under age 21 and individuals age 65 and older who are receiving inpatient psychiatric care in the Arkansas State Hospital or the George W. Jackson Center. Re. MS 2070.

17. Developmentally Disabled Individuals who qualify for Home and Community Based Services. Re. MS 2075;

18. Aged Individuals who qualify for Home and Community Based Waiver Services. Re. MS 2076;

19. Newborn infants born to women determined to be Medicaid eligible when the infant was born. Re. MS 2080;

20. Individuals who qualify for services under the Alternatives for Adults with Physical Disabilities Waiver. Re. MS 2078;

21. Disabled children eligible for Medicaid under TEFRA. Re. MS 2090;

22. Illegal aliens who are eligible for emergency services only. Re. MS 2095;

23. Individuals who qualify for retroactive Medicaid eligibility. Re. MS 2100 (applies to all categories except Newborn Infants, PW-PE, QMB, SMB. QDWI, and Waiver Categories. Re. MS 2080, MS 5600, MS 2047, MS 2051, 2048, 2075, and 2076);

24. Individuals in Title XIX Long Term Care facilities who are eligible according to LTC criteria. Re. MS 3000;

25. Women eligible as Pregnant Women who meet the AFDC or Medically Needy standards of need. Re. MS 5000, 7000;

* 26. Pregnant women, infants and children (up to age 6) whose Income does not exceed 133 percent of the Federal Poverty Level, and children ages 6 and * older, who were born after September 30, 1982, whose family income does not exceed 100 percent of the Federal Poverty Level. Re. MS 5600;

If a hearing is not requested during the advance notice period, the planned termination will be completed. If a hearing is requested during the advance notice period, the County Office will forward a copy of the DCO-700 (if applicable) along with the DCO-1200 to Appeals and Hearings and delay action pending the hearing.

5521 Termination Actions Not Requiring Advance Notice

Assistance will be terminated without advance notice when:

1. The agency has factual information concerning the death of the recipient.

2. The agency has received a statement signed by the recipient that she no longer wishes to receive assistance, or that provides information requiring termination of assistance, and the recipient has indicated that she understands the consequences of providing the information.

3. The recipient has been admitted or committed as an inmate to a public institution.

4. The recipient's whereabouts are unknown and agency mail directed to her has been returned by the Post Office indicating no known address.

5. It has been verified that the recipient has been accepted for assistance in a new jurisdiction.

6. The recipient has been informed in writing at the time of initiation of assistance that assistance will automatically terminate at the end of a specified period.

5530 Other Changes

Changes other than termination will not require recipient notification. When the agency becomes aware of changes (e.g. address) appropriate verification will be secured and case and member information will be updated. When the change involves only member information, the DCO-56 will be completed for input showing only member items changed. When the change requires update of case information, the DCO-56 will be completed to show an "0" (Other) action type with appropriate case field changes.

All changes will be evaluated in regard to their impact on recipient eligibility before update.

5600 SOBRA MEDICAID COVERAGE OF PREGNANT WOMEN. INFANTS AND CHILDREN

The Sixth Omnibus Budget Reconciliation Act of 1986 (SOBRA) allowed states to provide medical services to indigent pregnant women, infants and children. Medicaid coverage for pregnant women could be continued through the end of the 60 day period beginning on the last day of a pregnancy, and coverage for infants/children could be gradually extended through the end of the month of the fifth birthday. Arkansas elected to take this option, effective April 1, 1987.

The Omnibus Budget Reconciliation Act (OBRA) of 1987 allowed states to extend SOBRA coverage. Postpartum coverage of pregnant women was extended through the end of the month in which the 60th day post parturn falls, (Re. MS 5740.1). This change was effective August 1, 1988. OBRA 1987 also allowed states the option of accelerating the extension of coverage of children, born after September 30, 1983, up to age 5 and the option of gradually extending coverage up to age 8. Arkansas implemented both of these options, extending coverage for children up to age 5, effective July 1, 1988, and gradually extending coverage up to age 8 (Re. MS 5740.2) by October 1, 1990.

The Omnibus Budget Reconciliation Act (OBRA) of 1989 mandated states to cover pregnant women and children under age 6 at 133% of Federal Poverty, effective April 1, 1990.

The Omnibus Budget Reconciliation Act of 1990 mandated states to provide Medicaid coverage to children born after September 30, 1983, who have reached age 6, and to extend coverage yearly until they reach the age of 19, with family income at 100% of the Federal Poverty Income Guidelines. This provision was effective July 1, 1991, in Arkansas.

*Titles XIX and XXI of the Social Security Act allow states the option of providing Medicaid coverage to children born earlier than September 30, 1983. Effective October 1, 1998, Arkansas has elected to expand Medicaid coverage to children born after September 30, 1982, and before October 1, 1983, with family income at or below 100% of the Federal Poverty Level. Medicaid coverage will continue to be extended yearly to these children until they reach the age of 19.

5610 Identification of Elioibles

*Medicaid eligibility under SOBRA is limited to pregnant women and infants/ children whose family income does not exceed the specified Federal Poverty Level income limits. Net income for pregnant women and children under age 6 cannot exceed 133% of the Federal Poverty Income Guidelines. Net income for children age 6 and up, born after September 30, 1982, cannot exceed 100% of Federal Poverty Income Guidelines. Countable resources will be compared to the Medically Needy Resource Levels for the number of individuals 1n the unit.

The pregnancy must be medically verified by a documenting statement, or by a birth/death certificate.

5615 Presumptive Eligibility - Pregnant Women Only (Category 62)

SOBRA allows the provision of Medicaid for ambulatory prenatal care during a period of presumptive eligibility (PE). The P£ period precedes the eligibility determination made by the County Office, and the PE period begins on the date that a Qualified Provider determines on the basis of preliminary Information that the net family income of the pregnant woman does not exceed 133% of the Federal Poverty Income Guidelines. No resource test will be imposed for presumptive eligibility. When a Qualified Provider has made this determination, the provider is required to notify the County Office in the pregnant woman's residence county within 5 working days after the date of determination.

additional time, the County Office Worker will acknowledge the request by sending a second DCO-002 that clearly specifies what information is needed by the end of the extended time period and will assist the applicant in obtaining information, if possible. If the information has not been provided by the end of the extended time period, a DCO-700 or system notice will be sent and, the application will be denied.

5720 Eligibility Requirements

1. Verification of Pregnancy - The pregnancy must be verified by a medical statement (Re. MS 5211) or, for applications made postpartum, by a birth/ death certificate or medical statement that verifies a pregnancy within the 3 months prior to the date of application. A DCO-62 completed by a Qualified Provider is acceptable as medical verification of a pregnancy.

2. Resources - The Medically Needy Resource Levels (MNRLs) are the resource standards used for S06RA eligibility. The general resource methodology is the same as that used in AFDC-Medically Needy cases (MS 7320 and FA 2310-2344). The unborn child will be counted in the MNRL for pregnant women cases, but not in cases where only children are eligible and the pregnant woman's needs are not included. For example, if an SSI recipient is pregnant, her needs would not be included in the SOBRA case for her children, nor would the unborn child be included in the SOBRA need standard.

* 3. Income - Net income for pregnant women, infants and children up to age 6 cannot exceed 133% of the Federal Poverty Income Guidelines for the appropriate number included in the budget (Re. MS 5730). Net income for children ages 6 and up, born after September 30, 1982, cannot exceed 100% of the Federal Poverty Income Guidelines. The AFOC income disregards (Re. FA 2351) will apply. The AFOC earned income deductions (Re. FA 2365.1 and 2365.5) will be applied to gross earnings to determine net earned income, but the earned income exclusions (Re. FA 2365.2) will not be applied. Earned income will be verified according to FA 2361, and will be computed according to FA 2362.1. Any countable and verified unearned income will be added to net earned income to derive the net countable income.

If a pregnant woman under the age of 18 is living with her parent(s), the parental income will be deemed to the PU (Re. FA 2377 - 2377.2).

Lump sum payments will be considered income in the month received and, if retained, will be a resource in the month(s) following.

Income changes which occur after the first month of eligibility will be disregarded for the PU throughout the woman's pregnancy and the postpartum period of eligibility, (Re. MS 5740.1 for retroactive coverage and "No Look Back").

If the PU is not eligible for retroactive coverage and it is known prior to disposition of her application that income will increase in the month of planned certification, the increase in income will be verified to determine eligibility before certification is made for that month.

If It is known prior to certification of an eligible P\i that income will increase in the month(s) following the month of planned certification, the certification may be completed in the month of PU eligibility, with disregard of the future income increases.

SOBRA infant(s)/chi1d(ren) must be income eligible in each month of the certification period. If family income changes during a month, closure may be indicated. If family income fluctuates frequently, determine an average based on best information available, document the average, and leave the infant/child(ren) in SOBRA. However, the casehead must continue to report income changes.

NOTE: Actual income will be used in the month of eligibility determination for SOBRA pregnant women. Prospective eligibility for SOBRA children will be determined using the FA multipliers (Re. FA 2361).

4. Citizenship or alienage (Re. MS 3324) and residence requirements (Re. MS 2200) must be met.

5. AFDC relationship and living with specified relative requirements for determining need (Re. FA 2250 - 2252.2) must be met. The unborn child(ren) and the father of the unborn, if in the home, will be included in the need standard with the pregnant woman. If there are other children in the home who meet the relationship requirement and are not stepchildren, they may be included in the standard, if necessary, to raise the need standard to a level that will allow eligibility for the PW. If inclusion of a child and the child's income will result in ineligibility for the PW, that child and the child's income and resources may be excluded. However, the unborn child will always be counted in the need standard for the pregnant woman.

If a pregnant woman under the age of 18 is living with her parent(s), the parent(s) will not be included in the need standard.

6. The Social Security enumeration requirement (Re. MS 1358) must be met.

7. Mandatory assignment of rights to medical support/third party liability (Re. MS 1350) will apply.

8. A referral to the Office of Child Support Enforcement (OCSE) is required for SOBRA cases containing eligible children only, if there is an absent parent (Re. MS 1355).

An OCSE referral is not required for a SOBRA pregnant woman, during her pregnancy or postpartum period, on children for whom she is receiving Medicaid. (Re. MS 1355).

Note: This provision applies to SOBRA pregnant women only.

5730 Federal Poverty Income Guidelines

The Federal Poverty Income Guidelines are the basis of income eligibility for SOBRA. Net income for the appropriate number of persons included in the need standard may not exceed the percent of the Federal Guidelines as indicated below. In order to achieve eligibility, net family income must be equal to or less than the standards shown below; if net family income is greater than the standard, the applicant is not eligible.

Monthly Standards (4/1/98)

Number in Standard	13396 - PW/Children Under aae 6	100% - Children aaes 6 and ud
1	$ 892.20	$ 670.83
2	1,202.55	904.17
3	1,512.88	1,137.50
4	1,823.20	1,370.83
5	2,133.55	1,604.17
6	2,443.88	1,837.50
7	2,754.20	2,070.83
8	3,064.55	2,304.17
9	3,374.88	2,537.50
10	3,685.20	2,770.83

For each additional person, add $310.32$233.00

5740 Periods of Eligibility

5740.1 Pregnant Woman Eligibility Period - Retroactive. "No Look Back" and Post partum Coverage

S0BRA eligibility for a pregnant woman may begin at any time during a medically verified pregnancy, and will be extended through the end of the month in which the 60th day postpartum falls. A PW who applies postpartum and is found SOBRA eligible in the month of delivery will be given the full postpartum coverage.

In determining eligibility for the PW, the worker must inquire if the PW had any medical bills of her own (paid or unpaid) in the 3 months prior to the date of application and, if so, determine retroactive eligibility for the retroactive period (there must be medical bills to give retroactive coverage and the medical bills must be verified - the bills must be for the PW - medical bills for other family members will not qualify the PW for retroactive PW coverage); if retroactive coverage is not given, the case record should be clearly documented to show that coverage was considered and why it was not given.

In conjunction with consideration of the retroactive coverage, if an applicant is found eligible in any of the 3 retroactive months, certify the case effective the earliest retroactive month of eligibility; there will be a "No Look Back" at later income increases, throughout the pregnancy and the postpartum period, even if the applicant is not income eligible in the month of application or in the month in which the 45th dav of the application falls.

Example: Mrs. Smith applies for SOBRA coverage on November 1, and is not income eligible in November or in December (the month, in which the worker is ready to dispose of the application). However, Mrs. Smith was income eligible and had incurred medical bills in August, September and October. The County will certify, Mrs. Smith for SOBRA coverage effective on the date of the earliest bill incurred during the retroactive period (but not more than 3 months prior to the date of application), and will not "look back" at her eligibility again (i.e., disregard the income Increase that made her ineligible in November, the month of application).

When the PW is eligible, the full postpartum coverage must be provided, as mandated by law. Based on the expected date of delivery given by the PW, begin counting 60 days on the calendar, with the delivery date as day one; the end of Medicaid coverage will be the last day of the month in which the 60th day falls.

Example: Mrs. Jones' expected delivery date is November 15, and the 60th day after November 15th is January 13th. Coverage will be given through January 31st.

The client will be given the responsibility of reporting a premature delivery or delayed delivery.

5740.2 Infant/Child Eligibility Period

* SOBRA eligible infants/children born after September 30, 1982, may remain eligible up to their ninetheenth birthday as long as they remain income and resource eligible and as long as they reside with their parent(s), or other specified relatives (Re. FA 2250 - 2252). Children born prior to October 1, 1982, are not eligible under SOBRA.

If an Infant/child is an inpatient on his/her birthday, as specified below, eligibility will continue until the end of the Inpatient stay, provided the infant/child remains income and resource eligible. (Infants/children with severe disabilities will be referred to Social Security for SSI determination).

Application made after termination of a pregnancy does not prohibit coverage for the infant/child, i.e., a mother need not be a certified Medicaid recipient at the infant's birth in order for the infant/child to receive SOBRA coverage, as specified below. A mother need not remain Medicaid eligible in order for the infant/child to qualify for continuing coverage.

1. Children Up To Age Six - Children up to their sixth birthday will be covered at 133% of the Federal Poverty Income Guidelines (e.g.. Infant through age 5).

2. Children Ages Six and Older - Children ages six and older, born after September 30. 1982. will be covered at 100% of the Federal Poverty Level. Eligibility may continue up to the nineteenth birthday.

5750 Retroactive Eligibility for Infants/Children

Eligibility for infants and children may be established for the 3 month period prior to the date of application. Application made after termination of the PW's pregnancy does not affect coverage for infants or children.

When retroactive eligibility is determined, the infant/child budget unit must meet the income and resources requirements for each of the retroactive months, i.e., the "No Look Back" consideration of income changes given to the PW does NOT apply to Infants and children.

5760 Authorization of Eligibility

The County Office Worker will complete the following tasks when approving an application:

1. Record all pertinent information in the case narrative (information included on forms need not be repeated).

2. Code Forms DCO-87 for reevaluation or next anticipated change.

3. Indicate approval and date on Form DCO-88 (Control Sheet).

4. If a category 62 PE case is open in the system, close the PE case one day prior to certification of the category 61 case, and enter an end date to the category 62 case equal to the date of closure.

5. On the day following closure of the PE case, the completed Form DCO-56 for a category 61 approval will be submitted for data entry on WACE and WAFM. If there is a previous family category case number (including a category 62), use that number for the category 61 case number.

Begin date will be the date of application, unless retroactive coverage is given. The begin date may overlap or precede the begin date of the category 62 presumptive case.

When certifying SOBRA cases where the pregnant woman is the only eligible member, the case will be certified in fixed eligibility ("AF" or "BF" action type, action reason "101") giving the PW coverage from the beginning date through the end of the month in which the 60th day postpartum falls, basing the postpartum end date on the expected date of delivery, and entering the end date in the "Med End Date" field. The PW will be entered in closed status with a "Y" in the budget indicator. A member close code of 34 (PW eligibility expired) will be entered in the woman's reason of close field. Entries of the date of close and close reason (34) will allow the system to terminate Medicaid eligibility on the last day of the month in which the 60th day postpartum falls.

If certification is made after termination of a pregnancy, the period of eligibility will be known to the worker, and the case should be certified in a fixed period of eligibility.

When certifying SOBRA cases where the pregnant woman is included with eligible children, the case will not be certified in fixed eligibility ("A" or "B" action type will be used), but the PW will be certified in closed status (following instructions above).

NOTE: Though the pregnant woman and child are budgeted separately, both will be included on the DCO-56 with the child's prospective income.

The infant may be added to the mother's case (if open) with eligibility effective the birth month, if application has been made and if the infant is found eligible. If the mother's case is in closed status, the case must be reopened to add the infant, but the mother should remain in closed status and her Med End Date unchanged. If application for the infant/child is made after the mother's category 61 case has been closed and if eligibility is established, use the mother's category 61 closed case number as the case number for the infant/child. If there has never been a category 61 case for the mother, obtain a new case number for the infant/child in category 61, unless the infant/child has a previous family category case number.

When Newborn coverage (MS 2080) is given, the Newborn case may remain open for 1 year, and the newborn infant need not be opened in, or added to, a category 61 case. A reevaluation need not be scheduled as the system will close the case when the infant reaches one year of age.

6. Notify client of approval and the beginning date of eligibility on Form DCO-700 or by system notice. The end date for the PW will also be given.

NOTE: A PW "Minor Parent" (Under age 18) will always be given a "101" suffix.

5770 Denial and Withdrawal

The County Office Worker will complete the following tasks when denying an application.

1. Record pertinent information in the case narrative (information included on forms will not be repeated). Only the factor that makes the applicant ineligible must be verified. However, verification of other factors of eligibility that have been obtained will be recorded for future reference.

2. Indicate denial and date on Form DC0-88 (Control Sheet).

3. Complete the denial data on the first page of the DCO-95 and submit for data entry on WIMA.

4. Notify client by Form DCO-700 or by system notice. The referring Qualified Provider will also be notified by copy of the DCO-700 or memorandum if a previous category 62 PE determination was made.

5. * For withdrawal only, obtain a signed written statement from the applicant that she wishes to withdraw her application.

6. If a category 62 case has previously been approved, the case will be closed after appropriate 10 day notice.

If certification is made after termination of a pregnancy, the period of eligibility will be known to the worker, and the case should be certified in a fixed period of eligibility.

When certifying SOBRA cases where the pregnant woman is included with eligible children, the case will not be certified in fixed eligibility ("A" or "B" action type will be used), but the PW will be certified in closed status (following instructions above).

NOTE: Though the pregnant woman and child are budgeted separately, both will be included on the DCO-56 with the child's prospective income.

The infant may be added to the mother's case (if open) with eligibility effective the birth month, if application has been made and if the infant is found eligible. If the mother's case is in closed status, the case must be reopened to add the infant, but the mother should remain in closed status and her Med End Date unchanged. If application for the infant/child is made after the mother's category 61 case has been closed and if eligibility is established, use the mother's category 61 closed case number as the case number for the infant/child. If there has never been a category 61 case for the mother, obtain a new case number for the infant/child in category 61, unless the infant/child has a previous family category case number.

When Newborn coverage (MS 2080) is given, the Newborn case may remain open for 1 year, and the newborn infant need not be opened in, or added to, a category 61 case. A reevaluation need not be scheduled as the system will close the case when the infant reaches one year of age.

6. Notify client of approval and the beginning date of eligibility on Form DC0-700 or by system notice. The end date for the PW will also be given.

NOTE: A PW "Minor Parent" (Under age 18) will always be given a "101" suffix.

5770Denial and Withdrawal

The County Office Worker will complete the following tasks when denying an application.

1. Record pertinent information in the case narrative (information included on forms will not be repeated). Only the factor that makes the applicant ineligible must be verified. However, verification of other factors of eligibility that have been obtained will be recorded for future reference.

2. Indicate denial and date on Form DCO-88 (Control Sheet).

3. Complete the denial data on the first page of the DCO-95 and submit for data entry on WIMA.

4. Notify client by Form DCO-700 or by system notice. The referring Qualified Provider will also be notified by copy of the DCO-700 "or memorandum if a previous category 62 PE determination was made.

5. - For withdrawal only, obtain a signed written statement from the applicant

that she wishes to withdraw her application.

6. If a category 62 case has previously been approved, the case will be closed after appropriate 10 day notice.

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