12ADM-02 - Transitioning Children from Child Health Plus to Medicaid Using Express Lane Eligibility

I. Purpose

The purpose of this Office of Health Insurance Programs Administrative Directive (OHIP/ADM) is to instruct local departments of social services (LDSS) on the procedures to follow to transition children from Child Health Plus (CHPlus) to Medicaid using Express Lane Eligibility (ELE).

II. Background

The Children's Health Insurance Reauthorization Act of 2009 (CHIPRA), includes many provisions designed to give states the tools they need to effectively enroll eligible children in Medicaid and the Children's Health Insurance Program (CHIP). One of the key provisions is to allow states to rely on findings from an entity designated as an "Express Lane agency" to determine whether a child satisfies one or more factors of eligibility for Medicaid or CHIP. Under this option, Express Lane agencies can provide information that the State Medicaid or CHIP agency can use to determine eligibility. Express Lane Eligibility also encourages states to use electronic methods of enrolling children to reduce the burden on families.

As provided for under Section 203(a) of CHIPRA, New York has amended its Medicaid State Plan to identify CHPlus as being authorized to make a finding regarding programmatic eligibility requirements for Medicaid. Under the amendment, when a child renews for CHPlus and screens Medicaid eligible, the eligibility information obtained at the renewal by CHPlus will be forwarded to the LDSS for purposes of determining eligibility for Medicaid.

Currently, when a child renews for CHPlus and screens Medicaid eligible, the child's legally responsible relative must apply for Medicaid on behalf of the child by completing an Access New York Health Care application. Express Lane Eligibility will streamline the application process and eligibility determination for CHPlus children who screen Medicaid eligible at renewal.

When a child renews for Medicaid and is determined ineligible due to excess income, an electronic file is sent to CHPlus when the Medicaid case closes. CHPlus enrolls the child based on the information obtained from the Medicaid renewal. This statewide process will remain unchanged.

III. Program Implications

Children who renew for CHPlus who are determined to have household income at or below the Medicaid threshold will be considered income eligible for Medicaid. A separate Medicaid application will not be required.

Express Lane Eligibility will help reduce the number of children that lose public health insurance due to transitioning from one public program to another, and will reduce the burden on local districts and families to independently establish Medicaid eligibility.

Child Health Plus plans annually renew eligibility for children enrolled in CHPlus. When calculating household income, CHPlus plans first screen to assess if the child is eligible for Medicaid. If the child appears Medicaid eligible, the child is given two months of temporary CHPlus coverage. Express Lane Eligibility allows CHPlus to send the information collected on the CHPlus renewal to the LDSS for the purpose of establishing a Medicaid case. The CHPlus plan will inform the family through the temporary enrollment notice that the renewal is being transferred to the LDSS to be processed for Medicaid.

The CHPlus renewal form has been revised to include an option to not send renewal information to Medicaid. This option is required under federal statute.

The manner in which case information is transferred to the district differs Upstate from NYC. In Upstate counties, case information from the CHPlus renewal will be sent by mail to the district. The district will enter the case information into WMS. In NYC, case information will be sent electronically and a Medicaid case will be generated in WMS.

IV. Required Action

A. Upstate

Beginning with CHPlus renewals received on or after May 1, 2012, for children who screen eligible for Medicaid, the CHPlus plan will send a copy, in some instances this will be an imaged copy, of the CHPlus renewal form to the LDSS in the county where the child resides. This information will be sent weekly. The CHPlus plan will use the attached transmittal form (Attachment I) to submit the renewal form and the screening worksheet to the LDSS. One transmittal will be used for each renewal submitted to the LDSS. This transmittal will identify the case as an ELE case for the Medicaid opening and should be retained in the case record to support the opening. The Medicaid start date should not be effective prior to the end date of the CHPlus coverage, which will be listed on the transmittal form. The CHPlus renewal form will include all of the information required to open a Medicaid case for the child, including all demographic information, residence, and income. If there is missing information on the renewal when it is received by the health plan, the health plan will complete the missing information with data from the file or by contacting the family, and initial and date the added information. When the child is an immigrant with satisfactory immigration status, CHPlus will also send copies of the immigration documents they have on file with the renewal. These documents are needed to accurately code the Alien/Citizenship Indicator (ACI), the Date of Status (DOS) and the Date Entered Country (DEC) in WMS. Children who do not have satisfactory immigration status, will not be forwarded to the LDSS for ELE. If a child does not have a social security number (SSN) but has applied for one, CHPlus will include a copy of the application for a SSN (SS-5) with the renewal packet. The LDSS must then follow up as per instructions in GIS 07 MA/010, "Social Security Number as a Condition of Medicaid Eligibility for Children."

The LDSS must process the CHPlus renewal within 30 days of receipt. Full coverage (01 coverage) must be authorized effective the first day of the month following the month in which managed care pulldown occurs if received prior to pulldown. This will allow the system to flip the coverage to 30 (managed care coverage) when the managed care enrollment is entered into the Prepaid Capitation Subsystem (PCP). Managed care enrollment must be entered the day following the establishment of the 01 coverage to avoid the system auto- assigning the child into a managed care plan. If the LDSS receives the CHPlus renewal after pulldown, the case must be held until the following month with full coverage authorized effective the first day of the next month.

No documentation is required for ELE cases with the exception of immigration documents. The information written on the CHPlus renewal and the screening worksheet is all that is needed to process the case. ELE cases are not to be pended for additional information. Since these will be child-only eligibility determinations, the financial maintenance policy does not apply. When there is an absent parent and the custodial parent has an active Medicaid or Family Health Plus (FHPlus) case, using local district procedures and in accordance with State policy, a referral must be sent to the Child Support Enforcement Unit (IV-D) if the case meets the referral criteria.

The LDSS must complete the following steps when processing an ELE case:

• Review the Clearance Report after registering the child to determine if the child has a previous Medicaid history including a Client Identification Number (CIN). If a CIN is found, it should be used to establish a Medicaid case;
• Complete a MBL budget to determine the correct Individual Categorical Code (ICC) for the child, using the income provided on the CHPlus renewal;
• Complete full data entry (all required fields in WMS must be completed);
• Authorize full Medicaid coverage for 12 months effective the first day of the month following the month in which managed care pulldown occurs;
• Send the appropriate CNS acceptance notice (Opening Reason Code C50, "Accept, All Covered Care and Services");
• WMS will validate the social security number (SSN) through the SSN validation process and confirm citizenship/identity using the SSA data match; and
• The day after the case is opened with 01 coverage, enroll the child in the same Medicaid managed care plan in which she/he was enrolled under CHPlus, when the plan also participates in the Medicaid program. If the child is in a health plan that does not participate in the Medicaid program (e.g., Empire Blue Cross/Blue Shield) enroll the child in the default plan. See Attachment II for a list of default plans by county. Enrollment reason code 01 should be used. A separate managed care enrollment notification is not required as the CHP notice will provide the enrollment information.

When the information from the Clearance Report shows that the child(ren) has a parent(s) already on Medicaid or FHPlus, the child(ren) must be added to the existing case. Since updated income information will be provided and the household count will include the parent(s) and any other siblings, the ELE information must be treated as a renewal for other household members with active Medicaid/FHPlus. The authorization period must be extended for 12 months for the entire household. This will ensure that one renewal period will be established for the household.

In counties where New York Health Options/Enrollment Center processes renewals, and an ELE case is sent to the LDSS, if a parent has an active renewal with New York Health Options/Enrollment Center, the LDSS must fax the ELE renewal to New York Health Options/Enrollment Center using the designated LDSS fax coversheet for the child(ren) to be added to the parent's case. New York Health Options/Enrollment center will expedite these cases and add the child(ren) to the parent's case following the process outlined in this OHIP/ADM.

B. NYC

The CHPlus program will send a file monthly, on the tenth of each month, to WMS to be processed automatically. The file will contain the following information needed to open a Medicaid child-only case: name, residency, date of birth, gender, social security number, categorical code, and the health plan identification number. Two new Individual Categorical Codes will be used for ELE cases. These codes are detailed in Section V. of this directive.

The following steps will be automated in order to process an ELE case:

• The CHPlus file will be matched to WMS to determine if the child is already active on Medicaid and/or whether the child was previously assigned a CIN. If a CIN does not exist, then one will be assigned to the child. If a CIN is found, it will be used to establish a Medicaid case for the child;
• The SSN will be put through the SSN validation process after the case is opened;
• Coverage will be authorized for 12 months (see section V. of this directive for further information;
• An acceptance notice (new Opening Reason Code A08 "Authorize Medicaid Coverage, CHP to Medicaid") will be system generated; and
• The child will be enrolled in the same Medicaid managed care plan that the child was enrolled under CHPlus, when the plan also participates in the Medicaid program. If the child is in a plan that does not participate in the Medicaid program (i.e., Empire) the child will be enrolled in the default plan. The default plans are as follows: Bronx/Fidelis; Kings/United; New York/HIP; Queens/United; and Richmond/United;

A process is being developed for CHPlus to send immigration documents to the Human Resource Administration (HRA) for non- citizen children who are not known in WMS and appear on an error report. These documents are needed to accurately enter the ACI, DEC and DOS. Children who do not have satisfactory immigration status, will not be forwarded to the LDSS for ELE.

C. Statewide

For both Upstate and NYC ELE cases, documentation, including the DOH-4220, Access NY Health Care application, is not required to open a Medicaid case. At renewal, parents of ELE children, as with other individuals receiving community-based care, will be allowed to attest to income and residency. Therefore, the case record may not have any documentation of income or residency. Express Lane cases are not required to have such documentation in the case record. These cases are excluded from Medicaid Eligibility Quality Control (MEQC) and Payment Error Rate Measurement (PERM) reviews. In NYC, ELE cases will be identified by a unique Opening Reason Code A08 and Medicaid Center Code 556. Upstate workers must include a copy of the CHPlus renewal and the transmittal form from CHPlus in the case record.

V. Systems Implication

A. WMS

1. Upstate

There are no new system changes to WMS upstate. Local districts will be notified of any future enhancements.

2. NYC

A file containing all the information required to open a Medicaid case will electronically be transmitted from CHPlus to HRA on the tenth (10th) of each month. These cases will be identified with a new Medicaid Center Code

556 and a unique Opening Reason Code of A08. Coverage Code 06 (Provisional Coverage) will initially be used to open the case and then the child will be enrolled into managed care effective the first day of the following month. The Coverage Code will change from 06 to 01 (Full Coverage) and then flip to 30 to allow the managed care enrollment to take place. This will be done similar to the one step process currently in place. The following new Individual Categorical Codes will be assigned based on income level:

• 90 (Child From 6 to <19 above 100% FPL but at or below 133% FPL) or
• 91 (Child From 1 to <19 eligible for LIF or ADC; Child 1 to <6 at or below 133% FPL and Child 6 to <19 at or below 100% FPL).

These two new ICC's will be used only in NYC and only on ELE cases at opening. At renewal, if the LDSS becomes aware that the child has a parent(s) or sibling on a Medicaid or FHPlus case, the child must be added to the other household members' case and all eligibility rules apply (e.g., financial maintenance & IV-D).

B. CNS

1. Upstate - No changes at this time. CNS Opening Reason Code C50 "Accept, All Covered Care and Services" must be used.
2. NYC – CNS Opening Reason Code A08/ELE opening notice will be generated for ELE cases.

VI. Effective Date

The provisions of this Administrative Directive are effective May 1, 2012.

Upstate Medicaid Managed Care Default Plans by County

County	Default Plan
Albany	CDPHP
Chenango	Fidelis
Clinton	Fidelis
Columbia	Fidelis
Cortland	Fidelis
Delaware	Fidelis
Dutchess	MVP
Essex	Fidelis
Franklin	Fidelis
Fulton	Fidelis
Greene	CDPHP
Hamilton	Fidelis
Herkimer	Fidelis
Madison	Fidelis
Montgomery	Fidelis
Nassau	United
Orange	Hudson
Oswego	Fidelis
Otsego	Fidelis
Putnam	Fidelis
Rensselaer	CDPHP
Rockland	Fidelis
Saratoga	Fidelis
Schenectady	CDPHP
Schoharie	Fidelis
Suffolk	United
Sullivan	Fidelis
Tioga	Fidelis
Tompkins	Fidelis
Ulster	MVP
Washington	Fidelis
Westchester	Hudson