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03 – Processing an Application Case

Step 1: Participant Screening #

Tools

 

Question 1: Do you need to find a DCN or resolve duplicate DCN/MEDES IDs for any participants? See 01 DCN/Participant Screening

 

Question 2: Does the application include an adopted individual? See Adoption Review guide

 

Step 2: Multiple Applications (or New Application on Existing IC) #

Review for multiple Application Cases (AC) or existing Integrated Cases (IC) under the same Head of Household (HOH), or spouse of the HOH, and follow the below steps to determine the correct process as the new application to determine if the application is to be used to update a pending AC or existing IC. 

 

NOTE: To view HOH, from AC/IC Evidence Dashboard > Application Filer > HOH is the participant listed as the application filer. 

 

Question 1: Are there multiple ACs under the same HOH (or spouse) as the new application? Person Page > Home sub-tab > Application Cases

 

Question 2: Is there an active IC under the same HOH (or spouse) as the new application? Person Page > Home sub-tab > Current Cases

 

Question 3: Is there an inactive IC under the same HOH (or spouse) as the new application? Person Page > Information sub-tab > Cases Folder > Role column > Primary Client is the participant listed as the HOH

 

Question 4: After reviewing the 04 – Managing an Integrated Case / CIC guide, do you need to withdraw an Application Case?

 

Step 3: Work with Evidence below as Applicable #

Tools:

 

Note: If a child is receiving coverage in a different IC, see Step 18: Determine if CEC Transfer is Necessary

 

Question 1: Does the application case fit any of the three flexibilities? MAGI Applications received as FFM Referrals, Enrolling Parents into Medicaid Based on Children’s Income Eligibility or Targeted Enrollment SNAP Strategy?

Question 2: Was the application received through the Federally Facilitated Marketplace (FFM)?

Question 3: Use the Application Pre-work Checklist  and Clean Up Incoming Evidence. Use the instructions below for specific types of evidence as needed. Is all evidence complete and accurate?

      • Yes- See DCN Guide, Step 4: Transfer DCNs
      • No- Add/Update remaining evidence. Make changes as needed per the guides listed below:

 

Address Change #

Guidance: Always use the USPS Recommended Address, if it is not available, contact the participant to ensure that the address listed is correct

 

NOTE: Even if the participant has moved out of state, you MUST still add the new out of state address(s) in MEDES.

 

Question 1: Is the Address Change a Safe at Home Address?

Question 2: Is the Address Change on an Application Case?

 

Comment/Note

    • HOH Person Page
    • Note Subject: Change of Address
    • Note Body: Enter the following information as it applies:
        • Date Address Change Rec’d: Date new address became known to FSD
        • Rec’d by Method (EX-Change Report IM-145)
        • New Address
        • Any change in coverage as a result of change
        • Add’l Info: explain add’l or unusual info regarding change of address
        • If there is a different mailing address from the physical address case notes should be
          present to explain the situation
        • See MEDES Notes and Comments SOP for more guidance

 

Add-A-Person to an Existing Application Case #

Tools:

Guidance: It may be necessary to add an existing person to an existing application case if a person was inadvertently omitted from the Application Case.

TO ADD A PERSON TO AN APPLICATION CASE

    1. Navigate to the Application Case > Page Actions menu
        1. Hover over Guided Change
        2. Click the Add A Member… The Add A Member Wizard opens
      2. Enter Participant Details
        1. Ensure field Enter the date on which this person jointed the household</strong > field matches the Date Received field.
        1. The participant being added must be in the Common Area and then brought into MEDES. Follow instructions in the Search for a Person/Assign a DCN guide.
            1. Use the function after finding or adding the person in the Common Area
    2. Click Next
    3. Enter Personal Information details
    4. Click Next
    5. Enter Relationship details
        1. Note: If the relationship is unknown and the participant cannot be reached by phone, mark the relationship(s) as unknown between the person(s) being added and the household members. Once the remaining information has been entered, pend the action and send an IM-31A for correct relationship information. 
    6. Click Next
    7. Enter Tax Information details
    1. Click Next
    2. Enter Income details. Once you’ve entered new Income evidence, click Add New Income if there is an additional income source. Once you’ve entered all Income evidence, click Next.
    3. Review the Summary and click Finish
    4. As needed, click the toggle next to Add a Member to add evidence
        1. Insurance
        2. Disability
        3. Medical Bills
        4. Newborn Details
        5. Benefit
    5. Click the List Actions menu and click Mark Complete
    6. Click Yes Yes Button to confirm Mark as Complete
    7. Navigate to the Application Case (If necessary, refresh the screen to view the new member) > Dashboard folder.

 

Add any additional evidence

 

    1. Hover the cursor over the MO Medicare Self-Attestation evidence
    2. Select the Add Evidence icon
    3. Complete the MO Medicare Self-Attestation evidence for the new participant
    4. Select Save
    5. Hover the cursor over the Demographics link until the Add Evidence icon appears
    6. Select the Add Evidence icon
    7. Complete the Demographics Evidence wizard
        1. Received Date and Start Date: Enter current date
    8. Click Save Save Button
    9. Hover the cursor over the Address hyperlink > click the Add Evidence icon
    10. Complete the New Addresses required fields
        1. The Received Date and From Date should match and be the date the participant was reported in the home. 
        2. Select only the new participant being added from the Case Participant. 
        3. Select Mailing from the Type drop-down box
    11. Select Save Save Button
        1. Note: The above listed evidence is required; however, there may be additional evidence, such as Tax Filer status and Tax Relationships, that may need to be updated/added based on the household circumstances. 
    12. Update the new participants Application Details with the application ID found in the Application Filer evidence
    13. Navigate to the Application Case > Evidence sub-tab > Dashboard folder > Application Filer hyperlink. 
    14. Retrieve the Application ID
    15. Close the Application Filer page to return to the Evidence Dashboard
    16. Select the Application Details hyperlink
    17. Toggle open new participant.
    18. Select the List Actions menu
        1. Select Continue Edit
    19. Enter the Application ID
    20. Select Save Save Button
    21. Verify All Outstanding Evidence
    22. Navigate to the Person Tab of the person being added and see if the DCN has brokered from the Common Area to MEDES. If it hasn’t, follow the directions in the DCN Assignment/Transfer from Common Area.
    23. Close the Person Page Tab and return to the Application Case
    24. Complete Eligibility Determination

 

Comment

Subject Line: Add A Person to an Application Case

Comment Body should include:

    • Person being added 
    • Verifications included or any needed
    • any other changes such as income updates or tax filing status and relationship updates.
    • Date IMES/IIVE/Work number ran and if they are included in ECM (follow Policy on what should or should not be saved to ECM)

Follow guidance in Tools > CCIU Guides > MAGI for specific details on what should be included in a comment and/or verifications.

 

Application Filer Consent #

Application Filer Consent (AFC) Evidence, is the applicant or participant’s consent which allows FSD to access the IRS HUB to confirm the individual’s self-attestation of his/her circumstance. As FSD does not access the IRS HUB at application or renewal, this evidence is not necessary and does not need to be added or updated.

 

If the participant requests to alter/revise their consent, follow the instructions below.

 

Application Filer Consent Evidence
      1. From the Application Case > Evidence sub-tab > Dashboard folder
      2. Click the Application Filer Consent hyperlink
      3. Click the Toggle Toggle
      4. Click the List Action List Action Menu menu
      5. Select Edit
      6. In the Participant Details field, ensure the HoH is showing
      7. Ensure the Received Date and Start Date fields reflect the date of the most current AFC Evidence
      8. Check the Use External Data checkbox if the HoH gives permission to use information obtained electronically through external data sources
      9. In the Years To Renew Coverage field, type the number of years granted on the IM-1U or Application
      10. Click Save

NOTE: History for this piece of evidence will be available under the Corrections tab.

      1. Make a comment on the HoH Person Page describing action(s) taken

 

Authorized Representative #

Guidance

 

Queston 1: Is the participant requesting an Auth Rep?

        • Yes – Proceed to Question 2

Question 2: Enter a comment

Question 3: Does a notice need to be sent to the Auth Rep?

 

Date of Birth on an Application Case #

This guide gives instruction for editing a Date of Birth in MEDES on an Application Case or Integrated Case in MEDES.

Tools:

Edit Date Of Birth
    1. From the Person Page > Evidence sub-tab > Birth and Death Details evidence
    2. Select the List Action List Action Menu menu
    3. Select Edit
    4. Select the Date of Birth field
    5. Type the correct Date of Birth
    6. Select Save

 

 

Income #

 

Tools: 

 

Guidance

Question 1 – Is this Income being reported for Transitional MO HealthNet (TMH)?

Question 2– Is there existing income that has ended?

        • Yes– End Date Income continue to Question 3
        • No– Continue to Question 3

Question 3– Is there a new income source being added?

        • Yes – Follow direction in the Create Actual Income guide for the first month the income is received

Question 4 – Is this new income source expected to continue?

 

Discuss & Clarify

 

Review the Reasonable Compatibility guide for the process used to determine Reasonable Compatibility. When verifying income, using reasonable compatibility calculator, place a copy of the Reasonable Compatibility Calculator in the VFR.

 

When entering SSA and/or SSD Income Evidence, include the claim number.  Entering Claim Numbers on SSA/SSD Income Evidence

 

Negative Income must be entered in MEDES when the participant’s self-employment income minus allowable expenses; including depreciation, equals a negative dollar amount. Follow direction in the Enter Negative Income guide to capture Negative Income.

 

When an income type is reported as ‘Other’, clarification must be gathered to determine if the income is countable or non-countable.  Use FCR to contact the applicant to clarify the type of income and obtain verification if necessary. Update the income type in the eligibility system if there is one available that is more appropriate than ‘other’. If unable to clarify income type, leave income evidence pending and Generate a Request for Information 31A for income verification.

 

Verification

 

Follow FCR steps to verify.

    • Can we get it?
        • Paystubs (trump EOI’s when there are discrepancies)
        • Electronically Obtained Information (EOI’s)
          • Federal Data Hub
    • If customer needs to provide verification, common verifications are:

Comment/Note

 

    • HOH Person Page Note:
        • Label: Reasonable Compatibility
    • Evidence Note: Detail of the budget for the particular source of income.
        • List the method that the income was verified, list each date of pay shown, amounts for each dates of pay, and frequency of pay. Total the income amounts for each date of pay, divide the total amounts by the number of pay dates for the average amount of income each frequency dates.
        • Example: Paystubs provided for 1/1/2020 $400.00, 1/15/2020 $400.00, and 2/1/2020 $400.00. For a total of $1200.00 paid at an average of $400.00 semi-monthly.
        • If using EOI’s and the Reasonable Compatibility Calculator was used, state why used and the percentage difference in the participant’s Self-Attested Income and the EOI’s. Also state a copy of the calculator is filed in the VFR.
    • See MEDES Notes and Comments SOP for more guidance

 

Name Change on an Application Case #

 

NOTE: If the name change is due to an adoption, STOP and submit a ticket for an adoption review. Enter the Note below on the Head-0f-Household Person Page > Client Contact sub-tab > Notes folder:

    • Subject: Name Change – Adoption Review Needed
    • Body: Adopted participant has had a name change. This requires an adoption review by MEDES Support. Do not update the name in MEDES at this time.
 
Name Change in MEDES

    1. In the Common Area, always correct any incorrect customer information, such as name, date of birth, etc. on Common Client Data Update (SUPD).

        1. Use Correcting Information in the Common Area guide to Correct Name in the Common Area

    2. In MEDES, update the participant’s name on their Person Page > Evidence sub-tab > Evidence folder > Names evidence

      NOTE: Only enter Legal names in MEDES. Any name change must be verified before changing. MODL, IBTH and any legal documents listing the new name may be used as verification.

        1. Select the List Action menu

        2. Select Edit

        3. In the Edit Names pop up box, type the correct the name in the required fields

            1. When entering names:

                1. Enter the Legal or complete first name (i.e. Bob’s legal name may be Robert, or he may go by his middle name James Robert).

                2. If last name is hyphenated, enter as one name with no dashes or spaces (i.e. Smith-Jones is entered SmithJones)

                3. Enter the complete middle name if known. This helps identify the individual, which is extremely important with multi-cultural and common surnames, who may only have differing middle names. If only the middle initial is known, enter it.

                4. Enter suffixes when known (i.e. Senior (Sr.), Junior (Jr.), III, etc.). This helps to identify specific members of the same family.

        4. Select Save

    3. Open the Application Case. The name change should display for the participant.

      NOTE: If the name change does not display, stop. You will need to submit a MEDES Incident Ticket.

    4. Leave a NOTE on the HoH Person Page > Client Contact sub-tab > Notes folder stating:

        1. Date the name change reported

        2. Participant’s former name and new name

        3. What was used to verify the name change and where it is stored

        4. That the corresponding name change was made in the Common Area also

 

 

Pregnancy #

Tools

 

When a pregnancy is being reported, the Pregnancy evidence needs to be reviewed and dates updated, if needed, to ensure Post Partum coverage is granted correctly. Follow the below steps to review and update the pregnancy evidence.

 

Participants approved for MPW, including those whose pregnancy ended during the prior quarter period, have continuous eligibility through the end of the month 12 months after the pregnancy ends.

 

Note: If participant is transitioning from Non-MAGI to MAGI, add Disability evidence so continuous eligibility for referral to FAMIS will create if they are not eligible for coverage under MAGI at the end of the postpartum period.

 

Guidance

Step 1- Navigate to the Application Case page tab > Evidence sub-tab > Dashboard folder.

Step 2– Click Pregnancy hyperlink > click Open Toggle participant > click List Actions menu > select Edit.

Step 3– Was application for MPW made after the pregnancy ended?

    • NO: Review the required fields and update if necessary:
        • Received Date:
            • Use the date the pregnancy was reported to FSD.
        • Start Date:
            • Use the 1st day of the month the pregnancy was reported to FSD.
            • If PQ is requested, use the 1st day of the PQ month the pregnancy began or the 1st day of the month conceived, whichever is later based on the due date.
        • Due Date:
            • Use due date reported
            • If unknown, enter 8 months form the date of application based on the appropriate Level of Care as the due date. Use the Date Calculator to assist in determining this date.
    • YES: Review the required fields and update if necessary:
        • Received Date:
            • If the pregnancy ended the same month if was reported, use the date it was reported.
            • If the pregnancy ended in a month before it was reported, use the date the pregnancy ended.
        • Number of Unborn Children:
            • If 0 or field left blank, update to the number of unborn children the participant was carrying before the pregnancy ended.
        • Due Date:
            • Use the date the pregnancy ended. This should match the Pregnancy End Date field.
        • Pregnancy End Date: Use the date the pregnancy ended. DO NOT enter Pregnancy End Date in the End Date field. End Date field should be blank.
        • Start Date:
            • If the pregnancy ended the same month it was reported, use the 1st day of the month the pregnancy was reported.
            • If the pregnancy ended in a month before it was reported, use the 1st day of the first Prior Quarter (PQ) month the participant would have been eligible based on the birth of the child or the 1st day of the month the pregnancy end date occurred.
                • If the pregnancy ended on the 1st day of the month, use the 1st day of the previous month as the start date.
        • Postpartum Details:
            • Check the box Pregnancy Not Reported Timely if the pregnancy was reported more than 10 days after the pregnancy ended.
            • Only enter a date for Postpartum End Date if the participant:
                • Voluntarily requests coverage closed
                • Moved out of state
                • Was incorrectly determined eligible because of agency error, fraud, or abuse
                • Is in their postpartum period under a CHIP level of care and is opting to transition to a non-CHIP level of care
        • Due Date:
            • Use due date reported
            • If unknown, enter 8 months form the date of application based on the appropriate Level of Care as the due date. Use the Date Calculator to assist in determining this date

Step 4– Click Save

Reminder: PQ eligibility should only be explored if requested.

 

Prior Quarter  #

Tools:

 

Guidance:

If an IM-1SSL, web app, or a phone application is received, PQ is only pursued if requested by the participant. 

 

If PQ needs to be entered after the application has been registered, follow steps in the PQ Guided Change Wizard to enter the PQ evidence

 

 

SSN Details #

Tools:

 

Screen Help

    • IIVE

 

Guidance:

Question 1: Do you need to add a Social Security Number to a participant’s Person Page:

Question 2: Are you entering a Family Healthcare application in MEDES and the Social Security Number is missing:

Question 3: Are you adding ID Details Evidence with Type Social Security Number on the Application Case?

Question 4: Are you Editing ID Details Evidence with Type Social Security Number on the Application Case?

      •  

 

Tax Filing Status & Tax Relationship #

Tools:

Guidance: When a Participant’s Tax Filing Status changes from the Tax Filer to any other status, the ES must end-date all tax relationships where the participant is listed as the filer.

Question 1: Are you entering and application, adding a person to and Application or Integrated Case and do not know their Tax Filing Status or Tax Relationships to other household members?

Question 2: Are you changing a participant’s tax filing status?

 

Telephone Number #

When a participant with an AC reports a new phone number, use the directions below to add the phone number. This is a two-step process; you must first add the phone number to the Person Page and then accept it as incoming evidence on the AC. NOTE: Only add the phone number to the person reporting the change. DO NOT add the phone number for other household members.

 

Issue: Currently there is a known issue that adding any Type of phone number other than Personal/Home, will not update the phone number in the context section of the Person Page. If an existing phone number listed as Personal/Home is ended and a new phone number added with any Type other than Personal/Home, the ended personal/home number continues to display in the contest section of the Person Page.

 

Mitigation: If an existing phone number is correct but the Type is anything other than Personal/Home, end date the existing phone number and reenter with the Type as Personal/Home. When adding a new phone number, ensure the Type is entered as Personal /Home and explain in the Note. NOTE: This is a known issue so no Salesforce ticket is needed.

ADDING PHONE NUMBER TO AN APPLICATION CASE> (AC)

Add Phone Number To Person Page

      1. From the Person Page > Evidence sub-tab
      2. Ensure there are no other phone numbers showing in the Evidence list

NOTE: If there is already a phone number showing in the Evidence list, make sure it is not the number being reported. If it isn’t, you must end date it before adding the new phone number. If there is no phone number listed, proceed to step 3

          1. Click the List Action List Action Menu menu
          2. Click Edit
          3. In the To field, type the day prior to the day the new phone number was reported
          4. Click Save
      1. Click the Star Action Star Action Menu menu
      2. Click the List Action List Action Menu menu next to Phone Numbers
      3. Click Add
      4. In the New Phone Numbers popup box:
          1. In the Area Code field type the Area Code
          2. In the Phone Number field type the Phone Number
          3. In the Phone Type field click the drop down and select the type of phone number
          4. In the From field, click the calendar Calendar Icon icon and select the date the new phone number was reported

NOTE: The Received Date and From Date must match

          1. Click Save

NOTE: Refresh the screen and the new phone number should display in the Context section of the screen

 

Accept The New Phone Number On The AC As Incoming Evidence</strong >

      1. From the Application Case > Evidence sub-tab > Incoming Evidence Folder > Identical tab
      2. Locate the phone number you just added to the Person Page and click the List Action List Action Menu menu
      3. Click Accept
      4. In the Accept Evidence popup box, click the Yes Yes Buttonbutton

NOTE: If you end dated any other phone numbers on the Person Page, you must also complete steps 2 – 4 above for that number(s)

NOTE: There may be other evidence in the Incoming Evidence folder, Identical tab. Do Nothing with this evidence if you are only adding or changing a phone number

 

Step 4: Transfer DCNs #

Has MEDES transferred DCNs from the Common Area?

Step 5: Verifying Income Deductions #

There are certain types of deductions FSD will allow from a participant’s income. Deductions allowed for the calculation of MAGI income must be verified before allowing the expense.

 

Explore all available electronic data sources for verification prior to requesting this from the participant. If the participant does not provide the requested verification, authorize the Application Case without it. DO NOT reject the Application for failure to provide.

 

Related Evidence: Income

TO VERIFY INCOME DEDUCTIONS

Question 1: Is all evidence reviewed and checked for completeness and accuracy?

Question 2: Has the Application Prework Checklist been reviewed?

Question 3: Has all outstanding evidence been reviewed?

NOTE: Do not verify income source(s) until deductions are also verified. This allows MEDES to still pend while requesting proof of income deductions.

Question 4: Are there any income deductions to be verified?

NOTE: If the verification is not returned, authorize the Application Case without allowing the deduction

Question 5: Have the case details, changes validated, and eligibility been checked?

      •  

 

Step 6: Clean up Incoming Evidence #

Is there Incoming Evidence?

 

Step 7: Eligibility Check #

Has an initial Eligibility Check been completed?

 

Step 8: Is the Eligibility check correct? #

      • Yes- Step 9

 

Step 9: Is this an obvious case of ineligibility for ongoing and/or Prior Quarter coverage? #

 

Step 10: Citizenship Status #

Question 1: Is the participant reported as a US Citizen or US National? 

Question 2: Is the participant reported as lawfully present?  

      • Yes – Continue to Question 3
      • No – Aliens Not Lawfully Present do not require further verification and are ineligible for MO HealthNet benefits but may be eligible for SMHB if pregnant or emergency medical care (EMCIA). See 3.18 Emergency MO HealthNet Care for Ineligible Aliens. Then continue to Step 11.
        • NOTE: The eligibility system requires verification for the pregnant mother for “Citizenship without Identity” and “Identity” evidence.
          • For non-qualified immigrants, select “Other documentation verified by caseworker” as the Verification Item for SMHB cases.
          • Use the following comment when adding a verification item to these pieces of evidences: “Ineligible for MPW, SMHB explored. ID/Citizenship/SSN not required or verified due to non-qualified immigrant status.”

Question 3: Is the participant a Qualified Immigrant or a Qualified Non-Citizen? 

      • Yes –
        • Qualified Immigrant: Follow directions in the Verify Lawful Presence guide and refer to Refugee Processing SOP. Then continue to Step 11.
        • Qualified Non-Citizen: The system is not updated to process eligibility for COFA migrants. See COFA Mitigation for process when working applications that include any COFA migrants. Then continue to Step 11. 
      • No –Immigrants and Non-Citizens that are Non-Qualifying are ineligible for MO HealthNet benefits but may be eligible for SMHB if pregnant or emergency medical care (EMCIA). See 3.18 Emergency MO HealthNet Care for Ineligible Aliens, then continue to Step 11.
        • Note: If Citizen Status is Alien Lawfully Present but applicant is not a Qualified Immigrant or Qualified Non-Citizen, the Citizenship status must be updated to Not Lawfully Present to avoid incorrect eligibility.
      •  

Step 11: Incarceration #

Are you processing an application that has internal incarceration evidence where the participant is reporting incarceration information?

      • Yes -Follow directions in the Instructions-MEDES Application With Incarceration Evidence guide.
          • Make a separate note on the Head of Household’s notes about any suspended participant and forms sent.
              • HOH Person Page Note Subject: Suspended participant who will no longer return to the home after incarceration
                Note Body: Name of the suspended participant, how it was reported to FSD, who is the HOH, who is currently receiving MHN, other details regarding the information learned & a task was created for the Suspension Unit
      • No -Step 12

 

Step 12: Verify Outstanding Evidence and/or Removing Evidence Verification #

Tools

 

Question 1: Do you need to verify evidence on the Application Case?

NOTE: If approving a child(ren) for non-premium MO HealthNet and one or both of the parents are not in the home, see Cooperation in Pursuit of Medical Support

 

Question 2: Do you need to remove any evidence verifications on the Application Case? 

        • If Yes: 
          • From the Application Case > Evidence sub-tab > Verifications folder
          • Select the All tab within the Verifications folder
          • Toggle open the evidence piece you wish to remove evidence verification from
          • Scroll to the Verification Items Received section
          • Locate the Verification item
          • Click the List Action menu
          • Select Remove
          • Select Yes

NOTE: This piece of evidence has not been moved back to the Outstanding tab of the Verifications folder

 

 

Step 13: Validate Changes and Check Eligibility #

 

Review Case Details

Reviewing case details is the final step before checking eligibility and approving an Application Case. The Eligibility Specialist reviews the details for accuracy and to insure a correct eligibility determination. This is important because the BPT decides if the Eligibility check is correct based on MAGI policy.

Navigate to the Application Case page > Evidence sub-tab >Dashboard folder >click each evidence’s hyperlink to review for accuracy

 

Validate Changes

Before running the Eligibility Check on an Application Case, complete Validate Changes. This helps identify potential missing evidence.

    1. Navigate to the Application Case > Evidence sub-tab > Evidence folder
    2. Click the Validate Changes… Wizard
    3. In the Validate Changes popup box, click the box next to the word Type to select all evidence
    4. Click Save 
    5. If there are any evidence issues, MEDES will display a message identifying these issues.
    6. Authorize the Approval/Denial

 

Check Eligibility of an Application Case

An Eligibility Check must be ran prior to approving the Application Case to ensures MAGI policy is correctly applied.

 

    1. Navigate to the Application Case > Eligibility Checks sub-tab
    2. Click the Check Eligibility… Wizard
    3. Click Yes in the Check Eligibility request
        1. The most current Eligibility Check is at the top of the list.
        2. All members must have DCN assigned before a manual eligibility check can be performed. If DCNs are not assigned, you will receive a warning message. See Transfer DCN to MEDES for step-by-step instructions on how to assign a DCN.
    4.  Toggle open to review health benefit(s)

 

 

Step 14: Check MO Insurance Policy Details. #

 

If household member is covered by an insurance plan which not employer sponsored, evidence is created on the MO Insurance Policy Details screen. Refer to MO Insurance Policy Details to add MO Insurance Policy Details evidence. 

 

 

Step 15: Verifying Outstanding Evidence and/or Remove/Delete Evidence Verification #

 

Repeat Step 12, then continue to Step 16

 

 

Step 16: Request Verification #

Is there any evidence that is unable to be verified?

 

NOTE: If a Bypass is needed, see instructions below

 

 

Step 17: Authorize Case #

Question 1: Are all applicants ineligible based on the same eligibility factor?

Question 2: Are any people on the application receiving Alternative Care (AC) coverage through Children’s Division or receiving Presumptive Eligibility (PE) coverage?

Question 3: Are there only partial Household members eligible for MAGI? 

    • Yes –Determine if evidence verification or an Authorized Representative (IM-6AR) form is needed for the remaining members:
        • When eligibility can be determined for part of the HH but verification is required to determine eligibility for the rest of the HH, follow directions is the MAGI HH Individual Determinations: Verification Required guide.
        • When an application filer does not have the authority to apply on an individual’s behalf without an IM-6AR, follow directions in the MAGI HH Individual Determinations: IM-6AR Required guide.
    • No – Proceed to Authorize an Application Case. 

 

After running Eligibility Checks and verifying the correct decision is recommended, proceed with authorizing the application case. If the applicant has requested both Ongoing Health Benefits and Prior Quarter (PQ) Benefits, you can authorize both cases at the same time or authorize each case individually. NOTE: If participant(s) are not eligible for any benefit, you still authorize the decision. You are authorizing Product Delivery Case with zero benefits. 

 

To Authorize an Application Case

    1. Navigate to the Application Case page> Click Page Actions Menu
    2. Select Authorize
        1. If you have applications for both Ongoing Health Benefits and PQ Benefits, and if all evidence has been verified for both, clicking Authorize will authorize both cases. If verifications are missing from one of the two cases, clicking Authorize will only authorize the case with complete verifications.
    3. Click Save. The status of the program changes from Pending to Authorized (Press F5 to refresh screen to see the status change). Once authorized, the Application Case closes. An Integrated Case with an associated Product Delivers Case is created. 
        1. You do not need to leave a comment in the Authorize pop up box.  
        2. If applicable, see Cooperation in Pursuit of Medical Support if a CS-201 needs generated. The CS-201 should not be sent out to the HH until coverage requiring cooperation is authorized. For additional guidance, see MAGI CCIU guide, section CS-201.

 

Step 18: Determine if CEC Transfer is Necessary #

If the child is in their 12-months of continuous eligibility period and the child transfers to another household, the same continuous eligibility period will continue for the child. CEC period continues based on coverage determined in their original household and will be re-determined at Annual Renewal (AR). The child’s coverage would continue in the new houshold based on the coverage granted through the CEC EEE. Follow direction in the Add a Person on an Integrated Case.

 

 

Step 19: Note/Comment in MEDES #

HOH Person Page Label: Application Processed/Approved (or other outcome of the processed application)

Comment Body should include: 

    • Date Application Received:
    • Application Type: (online, FFM, telephone, paper):
    • Was PQ requested:
    • Insights Engine or IMES for all 16+ and explanation of what was viewed for each person:
    • IIVE for all HH members -date reviewed, and explanation of what was viewed for each person it was ran for (IIVE cannot be sent to ECM):
    • Actions taken on case:
    • Outcomes (including what LOC each person was approved for if authorized):
    • Were any calculators ran (RC calc or Chip Calc) :
    • What was sent to the ECM/VFR: (IMES/calculators/other documents provided by HH):

 

An additional Reasonable Compatibility comment is required if RC was used.  See Income for more information on this comment. 

 

Follow guidance in Tools > CCIU Guides > MAGI for specific details on what should be included in a comment and/or verifications or MEDES Notes and Comments SOP for more guidance

 

Step 20: Notices/Forms – MAGI #

Tools:

Notice Triggers

 

Guidance: 

  • Review Notice Queue to make sure appropriate forms generated based on actions taken
    • IM-33APQ: Prior Quarter Approval
    • IM-33RPQ: Prior Quarter Rejection
    • IM-33ARPQ: Prior Quarter Approval and Rejection
    • IM-33C: Case Action Notice

 

Step 21: When to Register a Non-MAGI Application #

Question 1: Is the applicant eligible for AEG and reported a disability OR eligible for MHF and a Medicare/SSI recipient or age 65+?

 

Question 2: Is the applicant eligible for UWHS only or not eligible for MHF/AEG benefits and a Medicare/SSI recipient, age 65+, or reported a disability?

 

Question 3: Was the application an FFM and the participant marked blind/disabled?

 

Bypass and Override #

Guidance

Question 1: Have you reviewed the Tips for using Override vs. Bypass guide?

Question 2: Will you be submitting a Bypass?

    • Yes – Review Bypass Entry guide
    • No – continue to Question 3

Question 3: Will you be entering MO Override Eligibility Evidence?

Question 4: Will you be editing MO Override Eligibility Evidence?

MAGI App Processing, MEDES MAGI
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