Entering ESI and Policyholder IS a Member of Integrated Case

 

Use this guide to capture evidence for a participant(s) who is enrolled in, and/or entitled to, Employer Sponsored Insurance (ESI) and the policyholder is a member of the Integrated Case (IC).

 

NOTE: This is a two-step process. The MO Employer Sponsored Coverage evidence must be captured and saved first. Next the New MO Covered Member evidence is captured and saved.

 

ENTERING ESI AND POLICYHOLDER IS A MEMBER OF INTEGRATED CASE

MO Employer Sponsored Coverage

    1. From the Integrated Case > Evidence sub-tab > Dashboard folder
    2. In the Household section of the Dashboard, hover over the words MO Employer Sponsored Coverage
    3. Click the Create Evidence icon
    4. In the New MO Employer Sponsored Coverage popup box:
      1. In the Received Date field, capture the date the insurance policy was reported to FSD
      2. In the Participant field, click the dropdown and select the policy holder for the ESI

NOTE: Do Not capture any information in the section ‘If the policy holder is not a case participant’ fields

      1. In the Coverage Status field, click the dropdown and select either Enrolled or Entitled
      2. In the Policy Start Date field, capture the date the participant was either Enrolled or Entitled to ESI
      3. In the Employee Contribution Field:
        1. If the participant is Entitled to ESI, capture the dollar amount the participant would pay for coverage for self and children per month if enrolled
        2. If the participant is Enrolled in ESI, enter 0.00

NOTE: When verifying MO Employer Sponsored Coverage evidence, in the comment field add a comment stating the premium amount.

      1. In the Family Planning Services fields, click the drop down next to each question and select Yes or No
      2. In the Maternity Services fields, click the drop down next to each question and select Yes or No
      3. Click Save

 

MO Covered Member

    1. From the Integrated Case > Evidence sub-tab > Dashboard folder
    2. In the Household section of the Dashboard, hover over the words MO Covered Member
    3. In the New MO Covered Member popup box:
      1. Click the radio button next to MO Employer Sponsored Coverage
      2. Click Next
      3. In the Received Date field, capture the date the insurance policy was reported to FSD
      4. In the Participant field, click the dropdown and select the participant who is covered or has access to the ESI
      5. In the Coverage Status field, click the dropdown and select Enrolled or Entitled
      6. In the Start Date field, capture the date the participant was enrolled or entitled to the ESI
      7. In the Monthly Cost to Enroll Participant in the plan field, enter 0.00
      8. Repeat steps 1 – 3g for each participant enrolled in or entitled to ESI

NOTE: The monthly cost for participants enrolled in ESI has been captured in the verification comments section of the MO Employer Sponsored Coverage evidence. The actual dollar amount the participant pays for enrolled coverage should NOT be entered into the employee contribution field. 0.00 should be entered in this field.

NOTE: If the case includes a participant applying for SMHB, capture the cost in the Monthly Cost to Enroll this participant in the plan field

      1. Click Finish
      2. Verify all Outstanding Evidence
      3. Apply Changes, Check Proposed Determination, Finalize Proposed Determination

NOTE: MEDES may generate an additional proposed determination, especially in cases with income changes, adding a person, or removing a person. If the system generated an additional proposed determination, you must run the Finalize Proposed Determination again

    1. Make a comment on the HoH Person Page to include: any Coverage Changes
    2. Review Notice Queue to make sure appropriate forms generated
      • IM-80: Generates in the event of negative coverage changes
      • IM-33C: Case Action Notice