Extended Eligibility Evidence/FAMIS Referral

Extended Eligibility is evidence in MEDES that holds coverage open for a participant(s) when another action is taking place that would close his/her coverage prematurely.

Extended Eligibility Evidence (EEE) is generated based on two types of actions that display as Exception Types:

  1. Exception Type based on a Decision:
    1. 60-Day CHIP
    2. Adverse Action
    3. IM-31A
      • These Exception Types should never be ended by staff. MEDES will end based on the date tied to the decision
  2. Exception Type based on an Action:
    1. Hearing (this is specific to the Hearings Unit and they take all actions on these)
    2. Referral to FAMIS
      • The Exception Type Referral to FAMIS is action generated and created by MEDES when a participant is actively receiving Family Healthcare. When one of the following is reported, the evidence(s) is captured, applied and finalized:
        • Receipt of SSI Income: Entered during a Change-in-Circumstance on an existing IC
        • Reports a disability (or already has Disability Evidence), and reports another change that would make him/her ineligible for Family Healthcare

When processing an application or CiC in MEDES, review the Evidence Dashboard for Extended Eligibility evidence

See: 13.3.6 Pre-closing MO HealthNet Review

 

MANAGE EXTENDED ELIGIBILITY EVIDENCE (EEE)

    1. Navigate to the Integrated Case > Evidence sub-tab > Dashboard folder
    2. If EEE is present, click the hyperlink to review

NOTE: If EEE Exception Type field is decision based, do nothing as MEDES will correctly end date

    1. For EEE Exception Type field that is action based, review FAMIS to see if the participant has a MHABD pending application or has been authorized or denied for MHABD

NOTE: If the MHABD application is still pending, do nothing as EEE needs to stay in place to keep benefits open in MEDES until a decision is made. Once the MHABD ex parte outcome is captured, this alerts the original MAGI worker to take action on the MAGI case.

    1. If the participant’s MHABD application has been authorized, denied or the participant(s) has moved out of state, the EEE must be end dated
    2. In the End Date field, capture the date prior to the date the MHABD application was authorized, denied or the participant(s) moved out of state
    3. Click Save
    4. Apply Changes; Check Proposed Determinations; Finalize Proposed Determinations
    5. A thorough NOTE must be captured on the HoH Person Page detailing why the EEE has been closed