Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 27 - Department of Medical Services
Rule 016.27.21-007 - Pharmacy 2-21 and Medicaid State Plan Amendment (SPA) 2021-0009, based on Act 758

A-210 Retroactive Eligibility

MS Manual 01/01/22

Refer to Health Care Procedures Manual for more information.

The State is required to provide retroactive eligibility for up to three (3) full months prior to the date of application to applicants who:

Note: Retroactive coverage for Newborns will not be given prior to the date of birth.

Note: Beginning May 1, 2018, Adult Expansion Group recipients may be eligible for retroactive coverage thirty (30) days prior to the date of application. Retroactive coverage for the Adult Expansion Group is date specific.

Example: James is approved for coverage in the Adult Expansion Group with an application date of September 15. He asks for retroactive coverage for a doctor bill with a service date of August 1. He is not eligible for retroactive coverage because his bill is for August 1 and retroactive coverage can only begin August 16.

Example: James is approved for coverage in the Adult Expansion Group with an application date of December 31. He asks for retroactive coverage for a doctor bill with a service date of December 1. His regular coverage will begin December 1. As the thirtieth day is included in his regular coverage period, no coverage will be given for the previous month.

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 (3) 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 eligibility worker 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 (that includes, without limitation: utilization review, benefit limitations, medical necessity). Prior authorization cannot be a condition of payment for services received during the retroactive period. However, such services are subject to the same Utilization Review standards as all other services financed under the State's Health Care (Medicaid) program. The State is not required nor obligated to pay for services which have been retroactively determined by Utilization Review to be unnecessary.

For cases in which an applicant has made partial or full payment for services received during the retroactive period, the state will make payment to the servicing provider if:

B-100 Eligibility Groups

MS Manual 01/01/2022

A Health Care eligibility group defines the eligibility requirements an individual must meet to be eligible for Arkansas Health Care coverage. The eligibility group also defines the benefit package or array of services the individuals in that group will receive.

Effective January 1, 2014, each of Arkansas' Health Care groups fall under one (1) of the following general groupings:

* Families and Individuals;

* Aid to the Aged, Blind, and Disabled;

* Foster Care & Adoption Assistance; or

* Emergency Services for Aliens.

Within these general groupings are more specific groups defined by specific individual characteristics, such as age or services needed (for example, Long Term Services and Supports). In addition, some groups are assigned two (2) or more categories of coverage due to differing benefit packages or federal funding match rates. These are described in more detail in the following sections.

B-200 Families and Individuals Group (MAGI)

MS Manual 01/01/2022

Most individuals under sixty-five (65) years of age will fall into the Families and Individuals general eligibility grouping. Most of the specific groups under this general grouping use the Modified Adjusted Gross Income (MAGI) methodologies to determine financial eligibility for individuals. (See MS E-200 for specific policy regarding the MAGI methodology.) Therefore, this group is commonly called the "MAGI" group. Generally speaking, the MAGI groups cover children and non-SSI adults under sixty-five (65) years of age who are not in need of specialized services or benefits related to a disability or blindness or who are not in need of Long Term Care Support or Services (See MS E-220). A non-SSI individual with a disability or blindness who is not eligible for or covered by Medicare may be covered in the Adult Expansion Group if otherwise eligible.

NOTE:Two groups (Newborns and Former Foster Care Adults) that are described below do not have a financial test and therefore, the MAGI methodology is not used. However, since these two (2) groups cover non-aged, blind, or disabled adults orchildren, they are included in the general grouping of Families and Individuals.

Individuals in all groups must meet the General Eligibility Requirements as outlined in MS D-100-540.

The sections that follow describe each of the specific Families and Individuals (MAGI) eligibility groups.

B-210 ARKids First

MS Manual 01/01/2022

The ARKids First group provides health insurance coverage for Arkansas children from birth to nineteen (19) years of age. There are two (2) categories of coverage in the ARKids First group - ARKids A and ARKids B. Along with the age requirement of being under the nineteen (19) years of age, relationship or living with a specified relative must be established for eligibility in these categories. (See MS F-110).

ARKids A provides coverage to children under nineteen (19) years of age with family income under one hundred and forty two percent (142%) of the Federal Poverty Level for the applicable household size (See MS E-110). ARKids A provides the full range of Health Care services. This is a mandatory eligibility group authorized and funded by Title XIX of the Social Security Act (Health Care).

ARKids B provides coverage to otherwise uninsured children under nineteen (19) years of age with family income equal to or over one hundred and forty two percent (142%) but under two hundred and eleven percent (211%) of the FPL for the household size (See MS E-110). ARKids B provides a more limited range of services with limited co-pays for some services. (See Appendix G) ARKids B was authorized by Arkansas Act 407 of 1997 (the ARKids First Program Act) and was implemented as a Section 1115 Health Care expansion program effective September 1, 1997. The program is currently funded by the Children's Health Insurance Program (CHIP) under Title XXI of the Social Security Act.

Because ARKids A and ARKids B have different benefit packages and have different federal funding match rates, it is necessary to designate separate categories of coverage for them.

Please see PUB-040, Arkansas Health Care, ARKids First & You for a summary of the benefit packages which highlights the differences in the two (2) packages.

B-220 Newborns

MS Manual 01/01/2022

This group consists of newborns up to one (1) year of age whose mothers were Health Care eligible at the time of their births. Newborns in this group are guaranteed Health Care coverage for the first year of life regardless of income changes that may occur during that first year. Newborns receive the full range of Health Care services.

Although this group is considered part of the ARKids First group, Newborns also have a separate category of coverage to ensure no change in household circumstances affects their one-year of guaranteed coverage. At one (1) year of age, eligibility for ARKids First (A or B) is determined as for any other child ( See MS I-230).

Newborns born to pregnant women approved under the Unborn child category ( See MS B-250) are also eligible for the Newborn category.

B-230 Parent/Caretaker Relatives

MS Manual 01/01/2022

This group consists of adults who have related minor children living in the home for whom the adult exercises care and responsibility ( MS F-110) and whose household income is below the income limit for this group (See MS E-110).

Both natural or adoptive parents may be living in the home with the child. There is no "deprivation of parental care or support" requirement for the parents to be included in this group.

If an adult meets the criteria for this group, they must be assigned to this group even if eligibility exists in another MAGI eligibility group. Therefore, eligibility for this group is determined first before moving to other categories that may have higher income limits.

NOTE: Only adults are included in this group. Children will not be placed in this group. Their coverage will be in the appropriate ARKids program or some other type of Health Care such as TEFRA, or a private insurance plan.

Adults covered in the group receive the full range of Health Care benefits.

B-240 Pregnant Women

MS Manual 01/01/2022

This group consists of women nineteen (19) years of age and above who are pregnant at the time of application and are not eligible in either the Parent/Caretaker Relative ( MS B-230) or Former Foster Care ( MS B-260) group. A pregnant woman can apply for retroactive Pregnant Women Health Care up to three (3) months after birth of the baby.

There are two (2) categories of coverage within the Pregnant Woman group.

* Those with household income at or below the income limit for Low-Income Pregnant Woman Coverage ( MS E-110) receive the full range of Health Care services; and

* Those with income above that limit but under the limit for High-Income Pregnant Woman Coverage (MS E-110) are provided services related to prenatal, delivery and postpartum care, and to other conditions that may complicate pregnancy.

Both levels provide postpartum coverage through the end of the month in which the sixtieth day from the date of delivery falls.

B-250 Unborn Child (Pregnant Woman)

MS Manual 01/01/2022

This group consists of non-citizen pregnant women who do not meet the alienage requirements for Health Care and whose household income is at or below two hundred and nine percent (209%) of the federal poverty level for the appropriate household size. This includes pregnant women who are either of the following:

* Lawfully admitted aliens who do not yet meet the five-year residency requirements or one (1) of the conditions listed in MS D-224; or

* Undocumented aliens.

The purpose of this group is to provide pre-natal care to the unborn child who is expected to be born in the United States. As this coverage is intended to benefit unborn children who will be U.S. citizens at birth, the pregnant woman will not qualify for this coverage if she intends to leave the U.S. before the baby is born.

This group is also different from the other Pregnant Women groups in that it receives an enhanced federal match rate under the Children's Health Insurance Program (CHIP). The CHIP enhanced funding coverage is available only to pregnant women who have no other insurance that covers pregnancy related services.

The non-citizen pregnant woman will receive postpartum coverage. Postpartum coverage is through the end of the month in which the sixtieth day from the date of delivery falls.

B-260 Former Foster Care Adults

MS Manual 01/01/2022

This group consists of adults up to twenty-six (26) years of age who aged out of foster care in Arkansas. There is no income or resource test. Other than the general Health Care eligibility requirements that all Health Care eligibles must meet (MS D-100), the requirements for eligibility in this group are that the adult was in foster care in Arkansas, was enrolled in Health Care when aging out of foster care at eighteen (18) to twenty-one (21) years of age depending on the individual circumstances and is currently under twenty-six (26) years of age.

Individuals in this group receive the full range of Health Care benefits.

B-270 Adult Expansion Group (ARHOME)

MS Manual 01/01/2022

The Arkansas Works Program was amended to become ARHOME starting January 1, 2022. Throughout this policy manual the ARHOME Program will be referred to as the Adult Expansion Group.

This group consists of adults who are nineteen (19) through sixty-four (64) years of age with household income equal to or below one hundred and thirty three percent (133%) (one hundred and thirty-eight percent (138%) with five percent (5%) disregard applied) of the applicable federal poverty level (MS E-110) and are not eligible in either the Parent/Caretaker Relatives group (MS B-230) or Former Foster Care group ( MS B-260). Adults who are blind or who have a disability may be covered in this group unless they are determined eligible for coverage in another group on the basis of the need for Long Term Care Services (facility or waiver) or other disability related services.

A woman who is pregnant at the time of application cannot be included in this group until after the postpartum period. She must be enrolled in one (1) of the pregnant women groups or in the Parent/Caretaker Relatives group if eligible. However, a woman who becomes pregnant after enrolling in this adult group may remain in the adult group throughout her pregnancy.

The ARHOME Program provides Health Care funding in the form of premium assistance to enable individuals to enroll in private health insurance plans.

Exception: Individuals eligible for the Adult Expansion Group, who have health care needs that make coverage through the Health Insurance Marketplace impractical, overly complex, or would undermine continuity or effectiveness of care, will not enroll in a private Qualified Health Plan (QHP) but will remain in Health Care(Re. MS A-100).

NOTE: If an individual in this group has a child(ren) under eighteen (18) years of age living in the home, the child(ren) must be covered in Health Care or have other health insurancecoverage.

Individuals eligible in the Adult Expansion Group will be enrolled in a Qualified Health Plan (QHP); unless they fall under one (1) of the coverages types listed below:

Medically Frail: Individuals identified as disabled or blind will be enrolled in Health Care under the Alternative Benefit Plan (ABP).

American Indian (AI)/Alaskan Native (AN): Individuals identified as an American Indian or Alaskan Native will not be enrolled into a QHP but will be covered under ABP in Health Care. Individuals in this group may opt into a QHP if that is the preferred coverage.

Enrollment in a PASSE is mandatory for the adult expansion group (ARHOME) that have been identified as in need of Tier 2 or Tier 3 behavioral health services through the Independent Assessment (IA) system (Re.Independent Assessment).

NOTE: Individuals who are moving to a QHP will be enrolled in Health Care under the Alternative Benefit Plan (ABP) for an interim period until the QHP plan is selected or the individual is auto assigned into a QHP.

B-300 Aid to the Aged, Blind and Disabled (AABD) Eligibility Groups

B-324 Qualifying Individuals 1 (QI-1)

B-310 Long Term Services and Supports

MS Manual 01/01/2022

The Long Term Services and Supports group provides coverage to eligible individuals in nursing facilities, home and community-based waivers, and the PACE program. Home and communitybased waivers and PACE community programs provide non-institutional Long Term services and supports to individuals as an alternative to institutionalization. Individuals eligible for waiver and PACE services must be potentially eligible for admission to a nursing facility.

B-311 Nursing Facility

MS Manual 01/01/2022

This group consists of individuals who are aged, blind, or have disabilities and are living in a Long Term Care Facility including an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID).

Nursing Facility coverage is provided to individuals who meet both categorical eligibility and medical necessity requirements. Refer to MS F-150-151. The individual's income cannot exceed three (3) times the current SSI payment standard. However, individuals with income over the limit may be eligible if they have established an income trust. Refer to MS H-110. The individual's resources cannot exceed two thousand dollars ($2000) and a couple's resources cannot exceed three thousand dollars ($3000).

Note: Refer to MS E-500 for resources and MS H-200- MS H-430 for spousal rules.

Note: A period of ineligibility will be imposed for uncompensated transfers. Refer to the MS H-300 section.

In addition to facility vendor payments, nursing facility eligibles receive the full range of Health Care benefits and services with the following exception:

B-312 Living Choices

MS Manual 01/01/2022

This group consists of individuals in licensed Level II Living Choices Facilities who are sixty five (65) years of age or older, or twenty-one (21) years of age or over and blind or have a physical disability as established by SSI/SSA or by the DHS Medical Review Team (MRT) or by Railroad Retirement. Living Choices Services are provided to eligible individuals to allow them to maintain their independence and dignity while receiving a high level of care and support. Living Choices coverage is provided to individuals who meet both categorical eligibility and medical necessity requirements. The individual's income cannot exceed three (3) times the current SSI payment standard. However, individuals with income over the limit may be eligible if they have established an income trust. Refer to MS H-110. The individual's resources cannot exceed two thousand dollars ($2000) and a couple's resources cannot exceed three thousand dollars ($3000).

Note: Refer to MS E-500 for resources and MS H-200- MS H-430 for spousal rules.

Note: A period of ineligibility will be imposed for uncompensated transfers. Refer to the MS H-300 section.

B-313 ARChoices in Homecare

Refer to Health Care Procedures Manual for more information.

MS Manual 01/01/2022

This group consists of individuals twenty-one (21) years of age or over. Individuals twenty-one (21) through sixty-four(64) years of age must have a physical disability according to SSA/SSI guidelines, Railroad Retirement, or the DHS Medical Review Team (MRT).

Services under ARChoices may be provided to individuals who meet both categorical and functional need requirements including requiring an intermediate level of care designation as determined by the Office of Long Term Care (OLTC). The individual's income cannot exceed three (3) times the SSI payment standard. However, individuals with income over the limit may be eligible if they have established an income trust. Refer to MS H-110. The individual's resources cannot exceed two thousand dollars ($2000) and a couple's resources cannot exceed three thousand dollars ($3000).

Note: Refer to MS E-500 for resources and MS H-200- MS H-430 for spousal rules.

Note: A period of ineligibility will be imposed for uncompensated transfers. Refer to the MS H-300 section.

Recipients of ARChoices receive the full range of Health Care benefits and services. However, the individual must accept the Waiver services provided by the program.

Note: Recipients of Health Care in the Workers with Disabilities group will be able to access services under ARChoices provided the functional need criteria for ARChoices have been met as well as the financial criteria of the Workers with Disabilities group.

B-315 TEFRA

MS Manual 01/01/2022

This group consists of children eighteen (18) years of age or younger with disabilities that must meet the medical necessity requirement for institutional placement in a hospital, a skilled nursing facility, Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID), or be at risk for future institutional placement. Medical services must be available to provide care to the child in the home, and it must be appropriate to provide such care outside an institution.

The income limit is three (3) times the current SSI payment standard. Only the child's income is considered. Parental income is not considered in the eligibility determination but is considered for the purpose of calculating the monthly premium. For information regarding TEFRA premiums and calculation, refer to MS F-170-172. The resource limit is two thousand dollars ($2000). Only the child's resources are considered. Parental resources are disregarded. Recipients of TEFRA Waiver receive the full range of Health Care benefits and services.

B-316 Autism Waiver

MS Manual 01/01/2022

This group consists of children eighteen (18) months through seven (7) years of age who have a diagnosis of autism. In addition to the autism diagnosis, the waiver participant must have a disability determination and meet the Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) level of care. The income limit for the child is three (3) times the current SSI payment standard and the resource limit is two thousand dollars ($2000). Parental income and resources are disregarded. Autism recipients will receive the full range of Health Care benefits and services in addition to intensive early intervention treatment.

B-317 PACE-Program of All Inclusive Care for the Elderly

MS Manual 01/01/2022

This group consists of individuals fifty-five (55) years of age or older who need nursing facility care to live as independently as possible. PACE is a comprehensive health and social services program that provides and coordinates primary, preventive, acute and Long Term Care Services. Individuals under sixty-five (65) years of age must establish physical disability through SSI/SSA, through the DHS Medical Review Team (MRT), or Railroad Retirement. In addition to the general eligibility requirements, the individual must require one of the four levels of nursing facility care of skilled, Intermediate I, Intermediate II, or Intermediate III. The individual must also meet special medical criteria as defined in MS F-155.

The individual's income cannot exceed three (3) times the current SSI payment standard. However, individuals with income over the limit may be eligible if they have established an income trust. Refer to MS H-110. Spousal impoverishment policy for income MS H-400- H-430 and resources MS H-200-212 will apply to PACE participants both in the community and in a nursing facility.

Transfer of resources ( MS H-300) will apply only if the PACE participant enters a nursing facility. The resource guidelines at MS E-500 will be followed. PACE services are provided in PACE Centers, in the home, and in inpatient facilities. The PACE program is only available in certain counties in Arkansas.

B-320 Medicare Savings Programs (MSP)

MS Manual 01/01/2022

The MSP groups provide Medicare savings by paying the Medicare premium(s) and possibly the Medicare deductibles and coinsurance. Except for ARSeniors, these categories do not provide for the full range of Health Care services. The groups are described below.

B-321 ARSeniors

MS Manual 01/01/2022

This group consists of individuals sixty-five (65) years of age or over whose income is equal to or below eighty percent (80%) of the Federal Poverty Levels (FPL). Recipients do not have to be entitled to Medicare (for example, Qualified Aliens who have not worked enough quarters to qualify for Medicare can still be eligible for ARSeniors). If the individual is entitled to Medicare, they must receive Medicare. If the individual chooses not to enroll in Medicare (if eligible), they are not eligible for the ARSeniors program. ARSeniors provides full Health Care coverage. Refer to M S F-190.

B-322 Medicare Savings Programs - Comparison Chart

Refer to Health Care Procedures manual for more information.

MS Manual 01/01/2022

B-330 Workers with Disabilities

MS Manual 01/01/2022

This group consists of individuals who:

* Have a disability;

* Are working at the time of application (Refer to Glossary for definition of working.);

* Are at least sixteen (16) years of age, but less than sixty-five (65) years of age; and

* Except for earned income, would be income eligible to receive Supplemental Security Income (SSI).

If an individual was not an SSI or SSA disability recipient, a disability determination must be made by the DHS Medical Review Team (MRT). Refer to MS F-122.

Substantial Gainful Activity (SGA) is not considered for the disability determination. In addition, the individual's total unearned income (minus the twenty dollar ($20) general exclusion) must be under the SSI payment amount for one (1) person to qualify for this group.

Recipients will be able to access services through ARChoices Waiver provided the medical criteria for ARChoices have been met as well as the financial criteria of the Workers with Disabilities group. Refer to MS C-240 for guidance and procedures regarding the medical assessment process.

Applicants will be advised by their eligibility worker that if they accept services from ARChoices Waiver providers while their applications are pending and are subsequently denied for ARChoices Waiver, they will be responsible for paying the provider.

Recipients of Health Care in the Workers with Disabilities category will be eligible for the full range of Health Care services.

B-340 Supplemental Security Income (SSI)/SSI Related Groups

MS Manual 01/01/2022

The SSI groups are SSI eligibles or special groups that lost their SSI due to SSA cost of living adjustment (COLA) increases, receipt of widow or widowers' benefits, or entitlement to or an increase in their Disabled Adult Child (DAC) benefits. These groups are described below.

B-341 Supplemental Security Income (SSI) Cash Eligibles

MS Manual 01/01/2022

This group consists of individuals who have been determined eligible for SSI benefits by the Social Security Administration (SSA). They are eligible for the full range of Health Care benefits and services.

B-342 Eligible Due to Disregard of Social Security Cost of LivingAdjustment (COLA) Increases (Pickle)

MS Manual 01/01/2022

This group consists of individuals who become ineligible for SSI payments due to Social Security cost of living adjustment (COLA) increases. It also includes individuals who lost SSI for any reason, if the individual would be SSI eligible today by disregard of all COLA's received on SSA benefits since the loss of SSI. The individual must have previously been entitled to SSA and eligible for SSI concurrently in at least one (1) month after April 1977. Individuals in this group must be current SSA recipients. They are eligible for the full range of Health Care benefits and services.

B-343 Health Care for Widows and Widowers with Disabilities (COBRA)

MS Manual 01/01/2022

This group consists of widows and widowers with a disability who became entitled to receive SSA benefits between fifty (50) and fifty-nine (59) years of age, entitled to SSA for December 1983 and lost SSI benefits after January 1984 due to an increase in SSA widow's or widower's benefits due to elimination of a benefits reduction factor. The individual must have continuously received widow's or widower's benefits since their SSI benefits were terminated and would be eligible for SSI if the amount of the 1984 reduction factor increase and any subsequent COLA increases were disregarded.

B-344 Widows and Widowers with Disabilities (OBRA 87)

MS Manual 01/01/2022

This group consists of widows and widowers with a disability who were at least sixty (60) years of age on or after April 1, 1988 and not yet sixty-five (65) years of age on April 1, 1988 and who were former recipients of SSI whose benefits were terminated due to entitlement to SSA widow's or widower's benefits. They must still be a current recipient of widow's or widower's benefits (may also receive concurrent other SSA benefits), not currently eligible for Medicare, would still be eligible for SSI if all SSA benefits were disregarded, and otherwise income and resource eligible for Health Care.

B-345 Health Care for Widows, Widowers with a Disability andSurviving Divorced Spouses with a Disability (OBRA 90)MS Manual 01/01/2022

This group consists of widow or widowers with a disability and surviving divorced spouses with a disability who lost their SSI due to receipt of SSA widow or widower or disabled surviving divorced spouse benefits. The individual must currently be (1) receiving SSA widow or widower or disabled surviving divorced spouse benefits, (2) not entitled to Medicare Part A, (3) would still be eligible for SSI if all SSA benefits were disregarded as income and (4) resource eligible under the AABD resource limits in MS E-500. Individuals found eligible under these provisions are entitled to the full range of Health Care benefits.

B-346 Disabled Adult Children (DAC)

MS Manual 01/01/2022

This group consists of individuals who lost their SSI after July 1, 1987 due to SSA Disabled Adult Children (DAC) entitlements or due to increases in their DAC benefits.

An individual who may be eligible for Health Care in this categorically eligible group is one who:

* Is eighteen (18) years of age or older;

* Was determined to be blind or have a disability before twenty-two (22) years of age;

* Was receiving SSI based on a disability determination or blindness; and

* Lost SSI on or after July 1, 1987 due to a DAC entitlement or a DAC increase.

B-400 Foster Health Care

MS Manual 01/01/2022

This group consists of children who are in the custody of the State of Arkansas because of removal from a parent or caregiver.

The eligibility criteria for this group are explained in MS Section K.

Children who "age out" of foster care at eighteen (18) or twenty-one (21) years of age, if an agreement has been signed by the child to remain in foster care, will be eligible for the Former Foster Care category of Health Care ( MS B-260).

B-500 Emergency Health Care Services for Aliens

Refer to Health Care Procedures Manual for more information. MS Manual 01/01/2022

This group consists of:

* Nonqualified aliens living in the U.S.; or

* Qualified aliens living in the U.S. for less than five (5) years.

Health Care benefits are available to pay for the cost of emergency services for aliens who do not meet the Health Care citizenship or alien status requirements or Social Security Number requirements. However, they must meet the financial and categorical eligibility requirements and state residency requirements for the category in which they apply, such as Parent Caretaker Relative, Medically Needy, Adult Expansion, ARKids A or B.

NOTE: Emergency Health Care applicants, if eligible in the Adult Expansion Group, may be approved for retroactive coverage thirty (30) days prior to the date of application. Retroactive coverage for the Adult Expansion Group is date specific.

To be eligible for emergency Health Care, the applicant must have, or must have had within the last three (3) months, an emergency medical condition. For the exception, see NOTE above. Labor and delivery is considered an emergency medical condition.

Emergency medical condition is defined as a medical condition, including labor and delivery, manifesting itself by acute symptoms of such severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in at least one of the following:

* Placing the patient's health in serious jeopardy;

* Serious impairment of bodily function; or

* Serious dysfunction of any bodily part or organ.

To qualify as an emergency, the medical condition must be acute. It must have a sudden onset, a sharp rise and last a short time. If the individual's condition is chronic (ongoing), including without limitation, cancer, AIDS, and end-stage renal disease, it is not considered acute and does not meet the definition of an emergency. If the chronic condition worsens, it is still not acute and does not qualify for emergency services. Federal policy specifically identifies care and services related to an organ transplant procedure as not qualifying under emergency services.

Before eligibility can be determined, the existence of an emergency medical condition must be verified by a physician's statement that the alien met the conditions shown above. A physician's statement that the individual will die without medical treatment does not in and of itself, constitute an emergency. The eligibility determination must include a determination of whether the condition is acute or chronic. Verification that medical expenses were incurred for treatment of the condition must also be presented.

Payment for emergency services is limited to the day treatment was initiated and the following period of time in which the necessity for emergency services existed. The date the alien first sought treatment is considered the first day of the emergency, regardless of the length of time the condition exists. The period of eligibility will be a fixed retroactive period, with the Health Care begin, and end dates entered in the system.

Medical Services Policy Manual, Section F

F-110 Age and Relationship

MS Manual 01/01/2022

Most Health Care eligibility groups have an age range in which the individual must fall to become eligible for coverage in that particular group. ARKids A and ARKids B also require a relationship and living with a specified relative requirement. To be eligible for ARKids A or B, a child must be living with a relative who is within the following degrees of relationship to the child:

F-120 Blindness and Disability

MS Manual 01/01/2022 42 U.S. Code §?1382c.

Some eligibility groups require an individual to either be blind or have a disability. The particular blindness and disability requirement for each eligibility group is listed in Appendix J.

Blindness is defined as having central visual acuity of 20/200 or less in the better eye (with correction) or a limited visual field of twenty degrees (20°) or less in the better eye.

Disability is defined as having a physical or intellectual disability that prevents the individualfrom doing any substantial gainful work (for a child under eighteen (18) years of age, the disability should be of comparable severity), and that meets the following criteria:

Blindness and Disability must be established by one (1) of the following means:

F-121 Social Security Administration

MS Manual 01/01/2022

Because SSA decisions are controlling, any new evidence or allegations relating to previous SSA determinations must be presented to SSA for reconsideration within sixty (60) days of the SSA denial notice. If the decision has not been appealed within sixty (60) days, the individual may still request a reopening of the decision within one (1) year.

Therefore, the agency must refer to SSA all applicants who allege new information or evidence which affects previous SSA determinations of "not disabled" for reconsideration or reopening ofa determination, except in cases specified in MS F-122. When the conditions in MS F-122 are met, counties will be required to make an eligibility determination for Health Care.

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 cashassistance and Health Care.

F-122 Medical Review Team (MRT)

MS Manual 01/01/2022

When an individual applies for Health Care and meets one (1) or more of the conditions below, required forms along with any medical records provided will be submitted to MRT, provided it appears that the other eligibility factors are met. Refer to Appendix I for required forms.

MRT will determine disability if any one (1) of the following conditions exists:

F-123 Dual Applications

MS Manual 01/01/2022

When an individual applies for both Health Care and Social Security Disability or SSI, and the application with SSA is still pending, if the individual appears to meet all other eligibility requirements a MRT determination of disability will be initiated. The agency will have ninety (90) daysfrom the date of the Health Care application to make this determination. If application for Social Security Disability is approved first, the Health Care application may be approved (if all other requirements have been met.) If application for SSI is approved first, the Health Care application will be denied except for ARChoices, Living Choices, Autism, DDS, NursingFacility (NF) and PACE which may be approved. If SSA determines the applicant is NOT disabled, the Health Care application will be denied.

If the Health Care application is approved based on a Medical Review Team (MRT) disability decision and later the individual is denied by SSA, the Health Care case will be closed after appropriate notice, unless the recipient appeals the closure. If the appeal is made within the ten (10) day time frame, the Health Care case will remain open pending the outcome of the DHS appeals process. In no case will the Health Care case remain open pending the outcome of the SSA appealsprocess if the recipient has appealed the SSA decision.

If the Health Care application is denied based on a MRT decision and later SSA approves the disability, when the applicant notifies DCO, the original application will be reinstated regardless of the time frame. If the provider files claims timely, Health Care claims will be paid. Refer to MS A-190. The application will be processed with the original application date provided all other eligibility criteria were met for this time period.

F-125 MRT Decision

MS Manual 01/01/2022

The Medical Review Team (MRT) will report the decision regarding physical or mental incapacity to the eligibility worker on a DCO-0109.

If an adverse action is taken on an individual's case, MRT will send a notice to the individual listing the specific medical records that were used in making the determination and the criteria that was not met.

If MRT finds that the medical information is not adequate to make a decision, further medical, psychiatric, and 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 eligibility worker on a DCO-0109. This decision of MRT will be final, subject to the regular appeal process, unless a later decision by SSA finds the individual not disabled.

F-130 Child Support Enforcement Services

MS Manual 01/01/2022

The Office of Child Support Enforcement (OCSE) is mandated to provide services to all Health Care recipients who have assigned to the state their rights to medical support. Each applicant or recipient who is responsible for the care of a dependent child must cooperate with OCSE in establishing legal paternity and obtaining medical support for each child who has a parent absent from the home. (See exception below.)

OCSE must provide all appropriate services to Health Care applicants and recipients without the OCSE application or fee. The OCSE agency is required to petition for medical support when health insurance is available to the absent parent at a reasonable cost. OCSE will also collect child support payments from the absent parent unless OCSE is notified by the recipient in writing that this service is not needed. Child support payments collected on behalf of Health Care recipients are received and distributed to the custodial parent through the Central Office Child Support Clearinghouse. However, no recovery cost will be collected.

F-150 Establishing Categorical Eligibility for Long Term Servicesand Supports (LTSS)

MS Manual 01/01/2022

Current recipients of SSI and Foster Care, for whom the Agency has legal responsibility, automatically meet the categorical eligibility requirement.

However, if any question regarding the categorical eligibility of these individuals should arise,the question will be resolved with either Agency or SSA personnel before proceeding further with the application. If the eligibility of an SSI recipient is questionable, a statement will be obtained from SSA (preferably written) to document its awareness and treatment of the eligibility factor.

Categorical eligibility for individuals other than SSI or Foster Care will be determined according to SSI-related AABD facility eligibility criteria as follows:

F-151 Functional Need

MS Manual 01/01/2022

Before nursing facility, waiver services or PACE can be authorized, it must be determined that the patient's condition warrants facility care or waiver services. Functional need decisions aremade based on the information submitted on the DHS-0703. The decision will be reported to the county office on the DHS-0704.

Functional need decisions for:

* Nursing facility applicants and recipients are made by the Division of Provider Services and Quality Assurance (DPSQA) Office of Long-Term Care (OLTC).

* Living Choices, ARChoices Waivers, and PACE applicants and recipients are made by theDivision of Aging, Adult and Behavioral Health Services (DAABHS).

* DDS waiver applicants and recipients are made by the Division of Developmental Disabilities Services.

* TEFRA applicants and recipients are made by the TEFRA Committee.

* Autism applicants and recipients are made by the DPSQA Office of Long-Term Care, Utilization Review.

Applicants for nursing facility admission with indicators or diagnoses of mental retardation or mental illness must be evaluated under Pre-Admission Screening and Annual Resident Review (PASARR) requirements for determination of appropriate placement prior to entering a nursing facility. Persons requiring pre-admission evaluations for mental retardation or mental illness shall not be eligible for Health Care reimbursement of nursing facility services prior to the date that a determination is made (the PASARR effective date on the DHS-0704), unless emergency admission has been prior authorized by the DPSQA Office of Long Term Care PASARR Coordinator or Utilization Control Committee.

ICF/IID applicants are exempt from PASARR evaluation, but they are not eligible for servicesprior to the decision date on the DHS-0704.

Redetermination of Functional Need

The DPSQA Office of Long-Term Care (OLTC) will periodically review and redetermine patient classification and necessity for continued stay in a facility when required. Classification and functional need reviews will be made only for individuals whose condition changes and for those admitted for convalescent care.

When OLTC finds that reclassification of a recipient is warranted, the reclassification informationwill be provided to the facility and to the eligibility worker who will make an adjustment to the vendor payments.

When continued stay in a facility is determined not to be functionally necessary including a determination due to a PASARR evaluation, OLTC will notify the facility administrator and the County Office by sending the DHS-0704. If it is a PASARR determination, OLTC will notify the recipient or their legal guardian by letter.

Recipients determined not in need of facility services will be allowed thirty (30) calendar days continued facility eligibility to arrange for relocation.

F-152 DCO Institutional Status

MS Manual 01/01/2022

Evidence of institutional status includes without limitation, any written document or record from a hospitalor nursing facility that verifies that the individual was in the hospital or nursing facility for thirty (30) consecutive calendar days. Refer to MS F-150.

When an individual cannot meet the institutional status requirement, the application will bedenied, unless the individual dies before meeting the thirty-day requirement. In that case, certification may be made for the actual days spent in the facility.

With medical documentation, such as a physician's statement, hospital records, etc., that the patient is "likely to remain" in the institution or facility for a period of thirty (30) days, the rules may be applied and the individual may be certified, if the individual is otherwise eligible, beforea period of thirty (30) days has passed. If the case was opened and the patient does not remain institutionalized thirty (30) days, no penalty will be imposed on the patient if there is likely to remain documentation in the case record. "Likely to remain" applies only to individuals in facilities with community spouses. Single individuals must meet the thirty (30) day institutionalization requirement.

When an individual has met the institutional status requirement of thirty (30) consecutive days, eligibility for facility services will be effective the date of entry into the facility if all other eligibility requirements are met, unless the individual is in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) or was subject to PASARR. Refer to MS H-440.

Note: The institutional status requirement does not apply to individuals who were certified for SSI or Foster Care in the month of facility entry.

Individuals who become ineligible for SSI or Foster Care following the month of nursing facility entry, will have their categorical eligibility determined according to SSI-related AABD facility eligibility criteria, with the exception of the institutional status requirement. Refer to MS F- 150.

F-155 Functional Need Criteria

MS Manual 01/01/2022

Individuals requiring services in ARChoices or Living Choices must be classified as requiring an Intermediate (I-A, II-B, III-C) Level of Care as determined by the DPSQA Office of Long-Term Care (OLTC).

Individuals classified as Skilled Care patients are not eligible for ARChoices (or Living Choices).

Individuals requiring services in a nursing facility or PACE must be classified as requiring a Skilled, Intermediate I-A, Intermediate II-B or Intermediate III-C Level of Care as determined by the DPSQA Office of Long-Term Care.

No individual who is otherwise eligible for Waiver services shall have their eligibility denied or terminated solely as the result of a disqualifying episodic functional condition or disqualifying episodic change of functional condition which is temporary and expected to last no more than twenty-one (21) days. However, that individual shall not receive Waiver services or benefits when subject to a condition or change of condition which would render the individual ineligible if expected to last more than twenty-one (21) days.

If an individual has a serious mental illness or has mental retardation, the individual will not beeligible. However, the diagnosis of severe mental illness or mental retardation will not bar eligibility for individuals having functional needs unrelated to the diagnosis of serious mental illness or mental retardation and meeting all other eligibility criteria.

Individuals requiring services in DDS must be classified as requiring an Intermediate Care Facilityfor Individuals with Intellectual Disabilities (ICF/IID) level of care.

ARChoices, Living Choices, and PACE

To be determined an individual with a functional disability, a licensed medical professional must determine an individual meets the criteria established by the Division of Aging, Adult and Behavioral Health Services (DAABHS) and the Division of Provider Services and Quality Assurance (DPSQA) Office of Long-Term Care.

DDS

To be determined an individual with a developmental disability, DDS will administer a comprehensive Diagnosis and Evaluation. Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) eligibility is determined based on a schedule according to the individual's age.

DDS will develop an individualized plan of care which will be reviewed within six months of theinitial assessment and, again, prior to twelve (12) months from admission to the program. Thereafter, DDS Plan of Care reviews will be completed annually.

F-160 Primary Care Physician Requirements

MS Manual 01/01/2022

A Health Care case can be approved before a Primary Care Physician (PCP) is selected; however, the PCP must be selected before most services can be accessed.

F-161 Primary Care Physician Managed Care Program

MS Manual 01/01/2022

ConnectCare is the Arkansas Health Care Primary Care Case Management (PCCM) system. In ConnectCare, a Health Care recipient chooses a physician or single-entity provider, such as Area Health Education Centers (AHEC), Federally Qualified Health Centers (FQHC), or family practice and internal medicine clinics at the University of Arkansas Medical Sciences campus, who is responsible for the management of the recipient's total care.

Each Health Care recipient must choose a Primary Care Physician (PCP) except those who:

* Have Medicare as their primary insurance;

* Are in nursing facility or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID);

* Are Medically Needy Spend Down only;

* Have retroactive eligibility only; or

* Are temporarily absent from the state.

Generally, a recipient must receive medical services from only the PCP or from the medical provider referred to by the PCP. There are some services which are excluded from the Primary Care Case Management (PCCM) system. A recipient can receive these services without a referralfrom the PCP. Refer to Form DCO-2613, Notice to Health Care Applicants/Recipients, for a list of these excluded services.

F-171 Determining Monthly Premiums

MS Manual 01/01/2022

The amount of the premium will be determined based on the custodial parent(s) total gross income as reported on the applicable Federal Income Tax Return (for example, line six of the 2018 version of form 1040) less the following deductions:

* Six hundred dollars ($600) per child, biological or adopted including the waiver child,who lives in the home of the waiver child and is listed as a dependent child on the applicable Federal Income Tax Return of the parents; and

* Excess medical and dental expenses as itemized on Schedule A of the Federal Income Tax Return of the parents (for example, line four (4) on the 2018 version of Schedule A).

Example 1: Family consists of five (5) people - mom, dad, TEFRA child, and two (2) minor siblings, living in the home. Total income on last year's Federal Income Tax Return showed sixty-five thousand four hundred seventeen dollars and fortyeight cents ($65,417.48). Excess medical and dental on Schedule A showed nine thousand four hundred sixty-three dollars and twenty-five cents ($9,463.25). All children in the home were included on the return.

* $65,417.48 - $1,800.00 ($600 x 3) - $9,463.25 = $54,154.23

Compare the adjusted income to Chart 1 in Appendix P. The income is above the limit for a family size of five. Go to Chart 2. The premium range for the adjusted income is from fifty-two dollars ($52.00) to seventy-eight dollars ($78.00).

Example2:Same family with less income reported.

* $46,500.00 - $1,800.00 ($600 x 3) - $9,463.25 = $38,336.75

Comparing income in Chart 1 in Appendix P, the annual income is below the limit for a family size of five (5). Therefore, no premium is required.

If the custodial parent alleges that household income has decreased significantly since filing the Federal Income Tax Return, additional verification can be submitted to determine current income.

Note: A stepparent living in the home will be considered a custodial parent and their income will be included when determining the premium amount.

See Appendix P for the amount of premiums to be paid. The maximum annual premium amount to be paid by any family is five thousand five hundred dollars ($5,500). Families having more than one (1) child receiving TEFRA Waiver benefits will pay only one premium for all covered children. There will be no increase in premium amount for additional Waiver children.

F-180 Other Health Insurance Coverage

MS Manual 01/01/2022

For most eligibility groups, an individual may be covered by other health insurance without affecting their eligibility for Health Care. There are two (2) exceptions to this which are described below.

Adult Expansion Group

An individual who is eligible for or enrolled in Medicare is not eligible for the Adult Expansion Group.

ARKids B

Children who have health insurance or who have been covered by health insurance other than Health Care in the ninety (90) days preceding the date of application will not be eligible for ARKids B unlessone of the following conditions is met:

F-190 Medicare Entitlement Requirements for Medicare Savings Programs (MSP) Eligibility Groups

MS Manual 01/01/2022

Medicare entitlement is an eligibility requirement for all Medicare Savings Programs (except ARSeniors), even though the requirement differs somewhat between the five groups. Medicareentitlement means that the individual has applied for, is eligible for, and is enrolled in Medicare Part A.

Conditionally eligible means that an individual can be enrolled (entitled) for Part A Medicare only on the condition that they are eligible for Qualified Medicare Beneficiaries (QMB), and thus eligible for the state agency to pay the Part A premium as part of the QMB benefits. The Medicare entitlements requirement is as follows:

* ARSeniors - Individuals do not have to be entitled to Medicare (for example, Qualified Aliens who have not worked enough quarters to Qualify for Medicare can still be eligible for ARSeniors). However, individuals who are entitled to Medicare and choose not to enroll in Medicare are not eligible for the ARSeniors program.

* Qualified Medicare Beneficiary (QMB) - Individuals must be entitled to or conditionally eligible for Medicare Part A.

* Specified Low-Income Medicare Beneficiaries (SMB) - Individuals must be entitled to Medicare Part A.

* Qualifying Individuals 1 (QI-1) - Individuals must be entitled to Medicare Part A.

* Qualified Disabled and Working Individuals (QDWI) - Individuals who lost Medicare Part A & SSA Disability Insurance Benefits (DIB) benefits due to Substantial Gainful Activity (SGA). The individual must be eligible to reenroll in Medicare Part A. Refer to MS F-192.

F-191 Medicare Part A Entitlement

MS Manual 01/01/2022

Medicare Part A beneficiaries include the following groups:

Persons sixty-five (65) years of age or older who are:

F-193 Initial Enrollment Period and General Enrollment Period for Medicare Part A

MS Manual 01/01/2022

A Qualified Disabled and Working Individuals (QDWI) applicant must reenroll for Medicare

PartA, if they have not previously reenrolled prior to making application.

The Social Security Administration will send notices to those individuals who lost or will lose Medicare Part A solely due to Substantial Gainful Activity (SGA), advising them to contact the SSA office. Once reapplication has been made for Medicare Part A, SSA will refer potentially eligible individuals to the County Office to make a QDWI application.

If an individual applies at the County Office prior to reenrolling for Medicare Part A, the individual will be instructed to contact the SSA Office to reenroll for Medicare Part

A and provide verification of reenrollment and the effective date of coverage.

The Individual Enrollment Period begins with the month in which the individual receives noticefrom SSA that their entitlement to Disability and Medicare will end solely due to SGA.

The enrollment period ends seven (7) months later.

There will also be a General Enrollment Period each year from January 1 - March 31.

Medical Services Policy Manual, Section G

G-100 Verification Standards

MS Manual 01/01/2022

Arkansas Act 1265 requires that the agency conduct electronic data matches first through the Federal sources and then through State sources if unable to obtain the required verification needed to determine eligibility for Health Care through the Federal source. However, additional verification sources may be used if there is a discrepancy between the information provided by the individual and the electronic data source or the information can't be verified through the data matches.

G-111 Eligibility Factors That Require Verification

MS Manual 01/01/2022

The following must be verified when determining eligibility for Health Care:

* Social Security Number (SSN);

* Citizenship;

* Alien Status;

* Income;

* Age and Date of Birth;

* Disability (when required); and

* Resources (for categories that require a resource test refer to MS E-110).

NOTE:When citizenship cannot be verified via the electronic sources, the applicant will be notified to provide verification of citizenship and identity. Refer to MS G-133.

Refer to sections below for specific information regarding verification of the above eligibility factors.

G-113 Verification Sources

MS Manual 01/01/2022

The primary source of verification is through electronic sources such as the Federal Data Services Hub (FDSH) and the Arkansas verification database, ARFinds. The FDSH is only available to the Family and Individuals Group.

The FDSH is a verification source that enables immediate access to multiple data bases via a single electronic transaction. Information provided by the individual will be verified through the federal data services by the following federal agencies:

* Social Security Administration (SSA) - Citizenship;

* Internal Revenue Service (IRS) - Income (Most recent Federal tax return information); and

* Department of Homeland Security - Immigration status.

The Arkansas verification database is a multiple source database directly integrated with the eligibility system. Information provided includes:

* SOLQi - Inquiry of SSA information;

* WESD (Workforce and Employment Security Data) - Wage history and unemployment insurance benefits;

* OCSE (Office of Child Support Enforcement) - Child support;

* Vital Records - Births, deaths, marriages, and divorces; and

* DMV (Department of Motor Vehicles).

Other sources of verification include:

* Paper Documentation provided by the individual;

[TICK] Check Stubs

[TICK] Employer Statements

[TICK] Bank Statements

[TICK] Collateral Statements

[TICK] Legal Documents (for example, guardianship court order)

* SNAP - verified information in the individual's SNAP record; and

* TEA - verified information in the individual's TEA case record.

G-114 Reasonable Opportunity for Providing Verification

MS Manual 01/01/2022

Verification must first occur through electronic sources. If unable to obtain verification though electronic sources, verification will be required from the client and a ten (10) day notice will be sent requesting the required verification. Additional time to provide the verification will be allowed if requested. Information that is not necessary to determine eligibility will not be requested.

G-115 Self Declaration

MS Manual 01/01/2022

For the Medicare Savings Program (MSP), self-declaration will be accepted for all eligibility requirements with the exception of alien status of non-citizens. Alien status must always be verified. If the declared income and resources are within the allowable amounts for the program, the client's declaration will be accepted. The eligibility worker, will however, view SOLQi on all applicants to confirm the accuracy of the gross benefits, Medicare claim number, and Medicare Part-A entitlement. If the applicant declares resources, the value of which would make them ineligible, and the eligibility worker cannot determine if the resource is countable (such as a life insurance policy or burial plan), the eligibility worker should then contact the applicant to determine if the resource is countable. The client's statement of the type of resource and the resource value will be accepted and documented. If it cannot be determined through contact with the client that the resource is countable, the client must be given the opportunity to provide a copy of the resource document.

G-120 Verifying the Social Security Number

MS Manual 01/01/2022

The SSN will be verified via the Federal Data Services Hub (FDSH) or through the SSN enumeration process for all individuals that have been entered into the eligibility system. If all match data agrees with SSA records, the system will be updated to reflect that the SSN has been verified.

If a mismatch occurs, an SSN mismatch report will be generated and the procedures in Appendix C will be followed to resolve the mismatch.

G-130 Verifying Citizenship

MS Manual 01/01/2022

Federal Law and Regulations require that citizenship must be verified for all Health Care recipients declaring to be citizens or nationals of the United States.

Exceptions to the verification requirement

Citizenship verification is not required for the following:

* Individuals entitled to or enrolled in Medicare;

* Individuals in receipt of SSI payments;

* Individuals receiving SSDI benefits based on disability;

* Children who are in foster care; or

* Children who are recipients of foster care maintenance or adoption assistance payments under Title IV-E.

G-131 Methods of Citizenship Verification

MS Manual 01/01/2022

Verification of citizenship will occur through the Federal Data Services Hub (FDSH) or SVES. If citizenship cannot be validated through the FDSH, the agency will conduct an electronic data match directly with Social Security Administration (SSA) or by obtaining acceptable documentation from the individual.

NOTE:Citizenship verified through the FDSH or SVES also verifies identity.

G-132 Reasonable Opportunity for Verifying Citizenship

MS Manual 01/01/2022

When citizenship cannot be verified through an electronic source or SVES, the agency will provide the applicant a "ninety (90)-day reasonable opportunity period" to provide the necessary documents to verify citizenship. (Refer to Appendix C).

NOTE:This reasonable opportunity period will be provided for all Health Care eligibility categories

Situations that may trigger the reasonable opportunity period:

* The individual is unable to provide a SSN, needed for electronic verification with SSA;

* Either the federal data services hub or SSA or Department of Homeland Security databases are temporarily down for maintenance or otherwise unavailable, thereby delaying electronic verification;

* There is an inconsistency between the data available from an electronic source and the individual's declaration of citizenship which the agency must attempt to resolve, including by identifying typographical or clerical errors; or

* Electronic verification is unsuccessful, even after agency efforts to resolve any inconsistencies, and additional information, including documentation is needed.

A notice will be sent to the applicant advising that verification of citizenship must be provided within ninety (90) days. The due date must be included on the notice. The reasonable opportunity begins on the date the notice is received by the individual. The date the notice is received is considered to be five (5) days from the date on the notice (day one (1)is the date of the notice). Eligibility for Health Care will begin on the same date the reasonable opportunity period begins.

NOTE:If the individual clearly shows that the notice was not received on the fifth (5th) day, the ninety (90) days will start from the date the notice was actually received.

If the needed verification for an individual is not provided within the reasonable opportunity period, then benefits for that individual will be terminated. Timely and adequate notice must be provided. Other eligible members for whom citizenship is verified will remain eligible.

When the recipient tries in good faith to present satisfactory documentation, but is unable to obtain the necessary documents and needs assistance (for example, homeless, mentally impaired, or physically incapacitated) and lacks someone who can act on their behalf, the eligibility worker should assist the recipient with obtaining the documentation of U.S. citizenship.

G-134 Subsequent Citizenship Verification

MS Manual 01/01/2022

Once an individual's citizenship is documented and recorded, any subsequent changes in eligibility should not require repeating the documentation of citizenship. If an individual's Health Care case is closed and he later reapplies, the worker will not need to request additional verification as long as proper documentation has been retained in the case file or narrated properly in the electronic record. However, if one (1) of the two (2) exceptions below occurs, the individual's citizenship must be verified again.

G-140 Alien Status Verification Requirements

MS Manual 01/01/2022

Alien status will be verified through SAVE (Systematic Alien Verification for Entitlement). If verification cannot be completed through this process, refer to MS Appendix C. When immigration status cannot be verified through SAVE, the agency will provide the applicant a "ninety (90) day reasonable opportunity period" to provide the necessary documents to verify immigration status.

In order to obtain verification from SAVE, the alien must provide the following information regarding alien status:

* Biographic information (first name, last name and date of birth); and

* Numeric identifier (alien number; form I-94, Arrival/Departure Record, number; Student and Exchange Visitor Information System (SEVIS) ID number; or unexpired foreign passport number).

If the alien does not have the required information, refer them to the Department of Homeland Security to obtain proof of status. Provide the individual with a ninety (90)day written notice requesting the information and extend notice if additional time is needed. If all other eligibility requirements are met, the Health Care begin date will be the first day of the month of application.

If the individual does not provide necessary information of alien status for the person requesting Health Care coverage, the individual will be eligible for emergency services only following the ninety (90)day reasonable opportunity period.

G-141 Reasonable Opportunity for Verifying Alien Status

MS Manual 01/01/2022

When alien status cannot be verified through an electronic source, Systematic Alien Verification for Entitlement (SAVE) or initial documentation provided by the individual, the agency will provide the applicant a " ninety (90) day reasonable opportunity period" to provide the necessary documents to verify alien status. (Refer to Appendix C).

NOTE:This reasonable opportunity period will be provided for all Health Care eligibility categories

A notice will be sent to the applicant advising that verification of alien status must be provided within ninety (90) days. The due date must be included on the notice. The reasonable opportunity begins on the date the notice is received by the individual. The date the notice is received is considered to be five (5) days from the date on the notice (day one (1) is the date of the notice).

The Health Care begin date will be the first (1st) day of the month of application if all other eligibility requirements are met.

NOTE:If the individual clearly shows that the notice was not received on the fifth (5th) day, the ninety (90) days will start from the date the notice was actually received.

If the needed verification for an individual is not provided within the reasonable opportunity period, then benefits for that individual will be terminated. Timely and adequate notice must be provided. Other eligible members for whom alien status is verified will remain eligible.

When the recipient tries in good faith to present satisfactory documentation, but is unable to obtain the necessary documents and needs assistance (for example, homeless, mentally impaired, or physically incapacitated) and lacks someone who can act on their behalf, the eligibility worker should assist the recipient with obtaining the documentation of alien status.

G-150 Income Verification

MS Manual 01/01/2022

Income verification for MAGI groups will occur in the following manner:

If a MAGI household attests to income over the MAGI income limit the system will accept the self-attestation and find the household ineligible due to income. The household will receive the appropriate notice and be referred to the Federally Facilitated Health Insurance Marketplace (FFM).

If the MAGI household has income (attested or previously verified) under the MAGI limit, the system will determine if a member of the MAGI household is on an open SNAP or TEA benefit case. If one MAGI household member is found on an open SNAP or TEA Cash case, the MAGI household income is considered verified.

If a member in the MAGI household is not found on an open SNAP or TEA Cash case, the system will continue the reasonable compatibility process and check available electronic data sources.

If the household attests to income under the MAGI limit (to include zero income) and the electronic data sources return no record of income or income less than the MAGI limit, the system will consider the MAGI household to meet reasonable compatibility and no further income verification is needed.

If the electronic data sources return an amount over the MAGI limit, the system will trigger a pending verification notice to the household for income verification.

For all other eligibility groups, sources for verification of income are electronic verification, data matches verified information from the SNAP record and documentation provided by the individual. If the income reported by the applicant exceeds the income limit, it is not necessary to check the verification sources. The applicant's statement of income may be accepted without further verification.

G-151 Reasonable Compatibility Standards for Electronic Data Sources

MS Manual 01/01/2022

Income is considered verified when the income reported by the individual is reasonably compatible with the income verified by the electronic data source.

Reasonable compatibility is met when the amount reported by the individual and the amount obtained through the electronic process are:

G-152 Reasonable Compatibility of Income Does Not Exist

MS Manual 01/01/2022

If there is a discrepancy between the information provided and the electronic data, the individual must resolve the discrepancy by submitting verification of the income. For earnings, this can be verified with check stubs, pay slips, or a collateral contact with the employer.

Sufficient verification must be obtained so that the actual income of the employee can be determined. The eligibility worker should not automatically assume that one (1) check stub accurately reflects earnings for an entire month. Verification of payment for the last thirty (30) days will be required if available.

Exception: For cases in which the individual has recently started employment and thirty (30) days of verification is not available, the eligibility worker will compute the income from the best information available. Verification of all, if any, paychecks already received by the individual or an employer's statement of anticipated earnings (for example, hourly wage or number of hours expected to work per week) should be obtained.

Verification of earnings from self-employment will be from the Federal Income Tax Return, purchase, sales, and account books or by any other source that establishes the source and amount of income. As soon as an individual is known to be engaged in a farming business or other self-employment enterprise, they will be advised of the necessity of keeping accurate records so that their income can be determined.

Verification of in-kind earned income (including without limitation, free rent and groceries) will be obtained from the employer. The verification must include the value of the in-kind benefit (including without limitation, the rent amount the client would otherwise pay and the cost of groceries provided) and how often it is provided (for example, monthly or weekly). If the amount fluctuates from week to week or month to month, verification of the in-kind earned income paid during the last two (2) months should be obtained.

Verification of unearned income is normally obtained from documentary evidence from the source (for example, an award letter). However, another source may be used if it clearly establishes the source and amount of income.

G-160 Age/Date of Birth

MS Manual 01/01/2022

Age and date of birth will be verified via the Federal Data Services Hub or other electronic sources. If there is a mismatch, a task will be generated and the eligibility worker will manually verify age and date of birth through birth certificate or other legal documents.

G-181 Verification of Resources using the Asset Verification System

MS Manual 01/01/2022

AABD applicant's and recipient's liquid resources will be verified using the Asset Verification System (AVS). Liquid resources include but are not limited to: checking and savings accounts, Certificates of Deposit, and bonds. The Asset Verification System will verify resource information for those categories with a resource limit. These categories include:

* Nursing Facility;

* ARChoices in Homecare;

* Living Choices;

* Program of All-Inclusive Care for the Elderly (PACE);

* Medically Needy Exceptional Category Aged, Medically Needy Exceptional Category Blind, and Medically Needy Exceptional Category Disabled;

* Medically Needy Spend Down Aged, Medically Needy Spend Down Blind, and Medically Needy Spend Down Disabled;

* Qualified Medicare Beneficiary (QMB);

* ARSeniors;

* Qualified Individual (QI-1);

* Specified Medicare Beneficiary (SMB);

* Disregard COLA Increase, Disregard (1984) Widow/Widower, Disregard SSA Disabled Widow/Widower, Disabled Widow/Widower Surviving Spouse, and Disabled Adult Child (DAC);

* Qualified Disabled and Working Individuals (QDWI); and

* TEFRA and Autism.

Exception: AVS will not provide verification for SSI Categories.

The information provided by AVS is a tool to help locate any liquid resources that the household may have or has had in the three (3) months prior to application or re-evaluation. The information that is returned by AVS will be used to verify the liquid resources that the household may possess.

The balances that will be received will show the balance of the account as of the first (1st) of the month. The AVS information received will be used as actual verification of liquid resources for the household.

*NOTE: While the AVS information is "known to the Agency", it is not considered verified information upon receipt for some benefit programs.

If the information that is returned from AVS causes ineligibility for the client, a ten (10)-day advance notice will be sent to the household allowing an opportunity for them to rebut the information that was provided by AVS. This will allow the household time to explain if there is a valid reason that the resources should not be included in the eligibility determination.

Any information that is received from AVS after the eligibility determination for an application or after the processing of a re-evaluation has been completed is known to the agency and will require appropriate case action.