View Categories

Eligible for both AEG and Non-MAGI (MHABD)

When a participant applies for MHN, eligibility will be explored in MEDES for Family MO HealthNet (MAGI) programs and Adult Expansion Group (AEG) coverage. If the participant indicates they are disabled, blind, or age 65 or over, MO HealthNet for the Aged, Blind, and Disabled (MHABD) Non-MAGI will be explored in FAMIS.

 

Explore all programs the participant may be eligible for. If the participant is eligible for more than one non-mandatory program or between AEG and a non-mandatory program, provide the participant the options to choose from. If the options are between mandatory programs, determine eligibility for the level of care that is higher on the hierarchy unless the participant requests otherwise. Refer to the Medicare Eligibility (ME) Code Chart/Hierarchy Level to determine if a program is mandatory or non-mandatory and its hierarchy level.

 

Follow the below directives when the participant is found eligible for AEG and Non-MAGI:

 

NOTE: FAMIS is NOT programmed to recognize any AEG eligibility factors except what staff enter in this field. Staff are responsible for knowing whether a participant is eligible for AEG or not and entering the correct Non-MAGI/AEG options code. Staff will be required to update the QMB/SLMB Decision (FMD6/QMBDEC) screen with information regarding Non-MAGI/AEG options. Staff will update the field during processing and before authorization, if completed on different days.

 

When the Participant is Eligible for AEG and a Non-Mandatory Non-MAGI program: #

Contact the participant by phone to discuss the participant’s options. The conversation should include the differences between the programs and any cost associated with the Non-MAGI program, such as a spend down or premium. The MO HealthNet Spend Down (MHSD) vs. Adult Expansion Group (AEG) Comparison Guide was developed to help staff understand the similarities and differences between these programs.

 

If Participant has Active AEG and Found Eligible for a Non-Mandatory Level of Non-MAGI: #

    1.  If the participant:
        1. Chooses AEG – Reject the Non-MAGI application by updating participant’s choice on the FMD6 screen in FAMIS to “A” and EDRES. Ensure a detailed comment about the conversation with the participant is entered on the Person Page in MEDES and EUMEMROL in FAMIS.
        2. Chooses Non-MAGI– Approve the Non-MAGI coverage and close AEG. Ensure a detailed comment about the conversation with the participant is entered on the Person Page in MEDES and EUMEMROL in FAMIS. Follow the Voluntary Closing guide to close AEG in MEDES. This will be a 2-day process.
    2. If unable to reach the participant by phone, the Non-MAGI processor must send an FA-325 Request for Information:
        1. Pend on BIRTH screen so the system will close correctly if the participant fails to respond by FA-325 expiration date.
        2. FA-325 language:

PARTICIPANT’S NAME CURRENTLY HAS ACTIVE MO HEALTHNET

ADULT EXPANSION COVERAGE BUT HAS ALSO BEEN FOUND

ELIGIBLE FOR COVERAGE UNDER THE MO HEALTHNET SPEND

DOWN PROGRAM. THE SPEND DOWN IS EXPECTED TO BE $XXX

EACH MONTH. IF PARTICIPANT’S NAME WOULD LIKE TO BE

TRANSITIONED TO SPEND DOWN COVERAGE, THEY MUST LET US

KNOW BY THE DATE LISTED ON THE TOP OF THIS FORM. IF

PARTICIPANT’S NAME DOES NOT RESPOND BY THE DUE DATE,

THEY WILL REMAIN COVERED UNDER MO HEALTHNET ADULT

EXPANSION PROGRAM AND WILL RECEIVE A REJECTION NOTICE

FOR MO HEALTHNET SPEND DOWN. THE REJECTION NOTICE

WILL SAY THEY ARE INELIGIBLE DUE TO FAILURE TO RETURN

        1. Enter a detailed comment on EUMEMROL with actions taken on the case, including why pending on BIRTH for a decision between MHSD and AEG.
    1. If the participant fails to contact FSD:
        1. FAMIS will deny the application for failure to respond to request for information
    2. If the participant contacts FSD to request Non-MAGI:
        1. Approve Non-MAGI coverage
            1. If within 10 days from when the request for contact is sent, approve the Non-MAGI application.
            2. If within the application due date, Cancel Reject the application and approve Non-MAGI.
            3. If after the application due date, treat as a new ex-parte request, register a new Non-MAGI application, effective the date of contact, and approve Non-MAGI coverage.
        2. Follow the Voluntary Closing guide to close AEG in MEDES. This will be a 2-Day process.
        3. Enter a detailed comment regarding any notices sent to the participant and action taken is entered on the Person Page in MEDES and on EUMEMROL in FAMIS.

 

If Participant has an Active Non-Mandatory Level of Non-MAGI and Found Eligible for AEG: #

    1. If the participant:
        1. Chooses AEG – Approve AEG and close the Non-MAGI Case. Ensure a detailed comment about the conversation with the participant is entered on the Person Page in MEDES and EUMEMROL in FAMIS.  Follow the REJECTING OR CLOSING MHABD CASES guide to close the Non-MAGI coverage. Use Reason Code AOA (Approved for other assistance) on the Reason field.
        2. Chooses Non-MAGI – Withdraw the MEDES Application . Ensure a detailed comment about the conversation with the participant is entered on the Person Page in MEDES and EUMEMROL in FAMIS.
    2. If unable to reach the participant by phone, the MEDES processor must send an IM-31A Request for Information to the participant.
        1. If no one else in the home is requesting benefits, leave the Identity Evidence pending verification so the system will close correctly if the participant fails to respond by IM-31A expiration date.
        2. IM-31A language:
            1. <Participant’s Name> currently has active MO HealthNet Spend Down coverage but has also been found eligible for coverage under the Adult Expansion Group.  If <Participant’s Name> would like to be transitioned to Adult Expansion Group coverage, they must let us know by the due date listed on the top of this form.  If <Participant’s Name> does not respond by the due date listed on the top of this form, they will remain covered under MO HealthNet Spend Down
        3. Enter a detailed comment on the HOH Person Page with actions taken on case, including Identity Evidence left pending for a decision between AEG and MHSD.
        4. If there are other participants in the household (HH) that are eligible for benefits and no other verification is needed to approve benefits:
            1. Change the Non-MAGI recipient’s app details to ‘not request’.
            2. Send IM-31A, DO NOT leave Identity Evidence pending.
            3. Authorize coverage for rest of the HH.
            4. Enter comment on HOH Person Page including
                1. Who was approved at what level of coverage
                2. Who the IM-31A for AEG decision was sent for.
    3. If the participant fails to contact FSD:
        1. MEDES will deny the application for failure to respond to the request for information.
        2. If the application was authorized to approve coverage for other HH members – leave the Non-MAGI recipients’ app details as ‘not requesting’ until they respond with a decision. A rejection notice is not needed.
    4. If the participant contacts FSD to request AEG:
        1. Approve AEG coverage.
            1. If within 10 days from when the request for contact is sent- Authorize application to approve AEG.
            2. If within 30 days of the application being rejected- Cancel Reject the MEDES application to approve AEG.
            3. If after 30 days of the application being rejected- Treat as a new ex-parte, register a new MEDES application, effective the date of contact, to approve AEG.
            4. If application was authorized to approve coverage for other HH members- Change the Non-MAGI recipient’s app details to ‘requesting’ and approve AEG.
            5. If after 30 days- end date the ‘not requesting” app details and add a new application detail segment as ‘requesting’ effective the date they contacted FSD.
        2. Close the Non-MAGI case using the Rejecting or Closing MHABD Cases guide. Use Reason Code AOA (Approved for other assistance) on the Reason Field.
        3. Enter a detailed comment regarding any notices sent to the participant and action taken is entered on the Person Page in MEDES and on EUMEMROL in FAMIS.

 

When the Participant is Eligible for AEG and a Mandatory Non-MAGI Program: #

MO Healthnet Non-Spend Down (MHNS) is a better level of coverage than AEG and must be selected as the participant’s coverage between the two. The Participant does not need to be contacted to deny or close AEG.

 

If participant has active AEG and found eligible for a mandatory level non-MAGI: #

    1. Approve mandatory Non-MAGI.
    2. Follow the Voluntary Closing guide to close AEG. This is a 2-day process.
    3. Enter a detailed comment on the HOH person page that AEG is being closed due to participant being eligible for mandatory Non-MAGI.

 

If participant has an active mandatory level non-MAGI and found eligible for AEG: #

    1. Deny the MEDES application using the MAGI Denying an Application guide.
        1. If a quick denial reason exists- quick deny the application.
        2. If a quick denial reason does not exist- authorize the application to deny coverage due to participant already receiving MHN.
    2. Enter a detailed comment on the HOH person page that the application is denied due to the participant being eligible for mandatory Non-MAGI.
Was this guide helpful?