GIS 16 MA/004: Referrals from NY State of Health to Local Departments of Social Services for Individuals who Turn Age 65 and Instructions for Referrals for Essential Plan Consumers

The purpose of this General Information System (GIS) message is to inform local departments of social services (LDSS) of changes to the referral policy for NY State of Health (NYSOH) Medicaid recipients and Essential Plan consumers who turn age 65. This GIS also provides instructions for processing undercare referrals for Aliessa immigrants enrolled in Essential Plan.

Previously, continuous coverage was provided to Medicaid recipients who turn age 65 and no longer qualify under the MAGI category (i.e., are not a parent or caretaker relative). Coverage for these individuals was continued until the end of their 12-month authorization period, and they were transferred at renewal from NYSOH to the LDSS.

As outlined in GIS 15 MA/22, effective January 1, 2016, Medicaid recipients who turn age 65 and who no longer qualify under the MAGI category are not eligible for continuous coverage. Due to this new policy, NYSOH will now refer these Medicaid recipients to the LDSS upon identifying them as turning age 65. Essential Plan consumers will also be referred to the LDSS upon identifying them as turning age 65. Only those individuals whose 65th birthday falls within a certain period of their renewal cycle will be referred to the LDSS at renewal.

• Exception: Incarcerated individuals who have inpatient hospital coverage only (coverage code 26)
  and are turning 65 will not be referred to LDSS until after they are released from incarceration.

On a monthly basis, NYSOH will identify Medicaid recipients and Essential Plan consumers who are age 65 or turning 65 within the next 45 days and refer them to the LDSS. This process will occur on approximately the 16th of each month. These referrals will be sent to the LDSS via the existing referral file process. The first batch of these referrals will be sent by NYSOH on approximately January 18, 2016 and will also include individuals who already turned 65 years old. The LDSS should expect to receive a higher than usual volume of referrals for that first month.

NYSOH will issue a notice advising the individuals that they are no longer eligible for Medicaid or Essential Plan through NYSOH due to turning age 65 and are being referred to the district. Generally, NYSOH will end the Medicaid or Essential Plan coverage at the end of the month following the month that the individual appears on the referral file.

Medicaid recipients and Aliessa immigrants enrolled in Essential Plan who are turning age 65 will receive an "undercare referral" with a referral reason code of HXNMD. Aliessa immigrants who were eligible for Essential Plan but not enrolled in a plan and Essential Plan consumers who are not Aliessa immigrants will be referred to the district as an "application referral" with a referral reason code of HXSUR. (They will not be required to elect to have eligibility determined on a non-MAGI basis in order to be referred.) Districts should process the referrals in accordance with the policies and procedures outlined in 14 OHIP/LCM-2, 13 OHIP/ADM-03, and the instructions listed below for Aliessa immigrants enrolled in Essential Plan.

Note: Medicaid recipients and Aliessa immigrants enrolled in Essential Plan who are turning 65 may have Medicare. Therefore, referrals for these individuals should be reviewed and appropriate action taken in accordance with the policies and procedures outlined in 14 OHIP/LCM-2 for individuals who have Medicare

Instructions for Processing Undercare Referrals for Aliessa Immigrants Enrolled in Essential Plan:

Unless advised differently in the below instructions, districts should process the undercare referrals (HXNMD, HXWMD, and HXNTX) for Aliessa immigrants enrolled in Essential Plan in accordance with the policies and procedures outlined in 14 OHIP/LCM-2.

As with all undercare referrals, districts are required to open a case on the Welfare Management System (WMS) and authorize Medicaid coverage effective the first day of the month that the referral is received plus three months for upstate districts or plus four months for New York City recipients. The case should be opened using Coverage Code 11 (Legal/Alien - Full Coverage) for these individuals.

The Individual Categorical Code (ICC) on the referral file will be blank. When opening the case, the district should use Category Code 09 (SCC Individual or Childless Couple) if the individual is under age 65 or Category Code 10 (Aged) if the individual is age 65 or over. The Category Code should be updated in WMS, if applicable, when the renewal is received and eligibility is determined.

If the State/Federal Charge Code on the referral file is blank, the district worker needs to contact his/her State Local District Support field representative, who will check for any documentation that may be present on the NYSOH and advise the district regarding the appropriate State/Federal Charge Code.

The Provider ID (PID) field on the referral file will be blank.

Note: Essential Plan consumers will appear as Case Type 26 on the clearance report.