PM 06-08-03-b

  1. (AIS) Prompts denial of an application.
    1. Prompts to deny, TAR 42, if:
      • the family is eligible for Family Health Spenddown only; and
      • there are no months of Assist, Moms and Babies, or Family Health Spenddown met; and
      • no persons under 19 are applying, or the family declines All Kids Share, All Kids Premium, and All Kids Rebate.
    2. revised textPrompts to deny, TAR 91, if:
      • for adults (age 19 and up), countable income is above 200% of the FPL for FamilyCare Rebate, or above 185% of the FPL for FamilyCare Premium; and
      • there are no months of Assist, Moms and Babies, or Family Health Spenddown met; or
      • for children (under age 19), countable income is above 300% of the FPL for All Kids Premium; and
      • there are no months of Assist, Moms and Babies, or Family Health Spenddown met.
    3. revised textPrompts to deny for the appropriate All Kids/FamilyCare Share, Premium or Rebate TAR if: 
      • countable income is equal to or less than the applicable income standard; and
      • there are no months of Assist, Moms and Babies, or Family Health Spenddown met); and
      • the person(s) applying is nonfinancially ineligible for All Kids/FamilyCare Share, Premium or Rebate.

        NOTE: The worker does not need to transfer the application to a U or W basic number before denying. Form 360KC is sent with the appropriate denial reason with the exception of TAR 18 (person has state funded insurance). A manual notice must be sent with TAR 18.

        Example: Ms. A applies for Rebate for herself and her 2 children. Ms. A's income is between 185% and 200% of the FPL. There are no Assist or spenddown met months. Ms. A is a state employee and has state administered insurance. AIS prompts to deny Rebate for Ms. A with TAR 18. The worker codes Item 39 to suppress the notice and issues a manual notice. 

  2. revised text(AIS) Prompts to approve Family Health Spenddown case if spenddown is met for the current processing month. Persons are not considered for All Kids/FamilyCare Share, Premium or Rebate because they are eligible for Medicaid.

    Example:
    Mr. and Mrs. B apply for medical benefits for themselves and their 3 children. Countable income is between 133% and 300% of the FPL. Eligibility is being determined on 07/12/11. The current All Kids processing month is 08/11. Due to an old hospital bill, spenddown is met through 09/11. AIS prompts to approve the case for Family Health Spenddown. 
  3. revised text(AIS) Prompts to transfer the Assist basic number to a U or W basic number with TA 62/TAR 42, if:
    • countable income is greater than 133% of the FPL and within the appropriate income standard;
    • there are no Assist or Family Health Spenddown met months; and
    • all nonfinancial All Kids/FamilyCare Share, Premium and Rebate requirements are met.

      For Premium, if income is over 185% of the FPL and an adult(s) is also applying, they remain in the case when it is transferred to the W basic number. When the All Kids Premium case is determined eligible, the adults are found ineligible due to excess income.

      One notice is sent to the family. Form 360KC states that the person(s) under age 19 is eligible for the appropriate All Kids Premium program and that the adults are ineligible due to excess income.

      Example: Ms. R applies for All Kids for herself and her daughter, Renee. Income is between 185% and 200% of the FPL. There are no Assist or Family Health Spenddown met months. Renee has no health insurance.

      AIS prompts to transfer the application to a W basic. Transfer the application to a W basic using TA 62/TAR 42. Approve All Kids Premium Level 1 for Renee. Form 360KC will state that Renee is eligible for All Kids Premium Level 1 and that Ms. R is ineligible due to excess income.

  4. revised text(AIS) Prompts to set up a Family Health Spenddown case and an All Kids/FamilyCare Share, Premium or Rebate case for the person(s) under age 19 if:
    • countable income is over 133% of the FPL and within the appropriate income standard; and
    • there is at least one month of Family Health Spenddown met eligibility which does not include the current processing month.

revised textIf countable income is over 185% of the FPL for Premium, and an adult(s) is also applying, set the adult(s) up in their own Family Health Spenddown case with a TA 11. Do this so that the adult(s)' case is not canceled when All Kids Premium eligibility begins for the person(s) under 19.

Example: Ms. C applies for assistance for herself and her daughter. Income is over 185% of the FPL. She requests backdating to 01/12. The All Kids processing month is 04/12. The only month of eligibility is 01/12 when spenddown was met. Set up separate Family Health Spenddown cases for Ms. C and her daughter.

  • Set up the All Kids Assist case for the child(ren) with a TA 10/TAR 75. TA 10 is used so that eligibility for Assist ends when eligibility for Premium or Rebate begins. The TA 10/TAR 75 period begins with the first backdate month and ends the day prior to beginning eligibility for All Kids Premium or Rebate.
  • When processing the TA 10/TAR 75 transaction, Box 41 is a required entry. Use of TA 10/TAR 75 automatically repends the application with the original application date. The TA 10/TAR 75 transaction cannot be processed through Batch Processing.
  • After approving the Assist case with TA 10/TAR 75, transfer the application to an All Kids Premium or Rebate U or W basic number.

revised textBecause the filing unit is different for All Kids/FamilyCare Share, Premium, Rebate, and Assist, sometimes the Assist calculation will be different from the Share/Premium/Rebate calculation. For this reason, after processing an Assist TA 10/TAR 75, redo the calculations to determine Share, Premium, or Rebate eligibility.

Example: Ms. Z applies for All Kids for her herself and her child on 02/22/12 and requests backdating to 12/11. Eligibility is determined on 03/27/12.

The family meets spenddown for 01/12 only. The child is eligible for All Kids Premium beginning 05/12 (current All Kids processing month).

Approve Ms. Z's Family Health Spenddown case in unmet spenddown status with TA 11/TAR 81. Submit a TA 55 transaction to meet spenddown for Ms. Z for 01/03.

Approve the child's Family Health Spenddown case in unmet spenddown status with TA 10/TAR 75. Box 41 04/30/12 (the day before All Kids Premium eligibility begins) and Box 77 = 01/01/12 (the first day of the first backdate month). AIS automatically repends the application with the 02/22/12 application date. The case is approved in unmet spenddown status because spenddown is only met for one month. Submit a TA 55 transaction to meet spenddown for the child for 01/12.

If a woman in the household is pregnant and income is below 200% of the Federal Poverty Level, approve the pregnant woman for Moms and Babies with a regular category 94 or 96 basic number.

It is very important for the worker to enter income for the entire 12-month period. If this is not done, the system will not determine eligibility for the persons under age 19 for All Kids Share, Premium or Rebate.

revised textOn the All Kids Case Progression Screen, AIS prompts to split the persons into different cases if some of the persons in the family are eligible for Share or Premium and some are eligible for Rebate. This will also happen when persons in the same family are covered by different health insurance policies.

Example: Ms. O applies for All Kids for her 2 children, Abby and Barry. Income is between 133% and 185%of the FPL and there are no Assist or Spenddown met months.

Ms. O carries health insurance on Abby but not on Barry. AIS prompts the worker to go to Add/Change/Delete and put Abby into her own case with a U basic number. Go to Change Case ID and transfer Barry's All Kids Assist application to a W basic number.