Premiums For Optional MEDICAID and F07 Children
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Premiums For Optional MEDICAID and F07 Children

Revised April 14, 2008


Advance Notice for Premium Amount Changes

Opting out Optional Child

Delinquent Premium

Sanction Exception Code

Premium Letters

Reports

Premiums for Optional Medicaid and F07 Children

  • ACES processes eligibility to determine if a child is a mandatory or optional medical premium participant. If the child is determined to be an optional participant ACES will determine whether they are exempt or non-exempt from the program. ACES will establish a premium amount for all non-exempt optional children. A child can be switched automatically back and forth from mandatory to optional or exempt to non-exempt status (dependent on the child’s age, pregnancy status, or the assistance unit income).
  • All related active F06/F07 Assistance Units with the same Head of Household will be looked at in determining the premium amounts. The three children with the highest monthly premium amount are added together to determine the household’s premium amount up to the household maximum standard.

Screens with Optional Medical Premium Information:

STAT
SANC
PREM
ELIG
MAFI
  • Household Premium Amounts can be viewed on the Household Premium Amount PREM screen. The PREM screen will display the household premium amount and any delinquent payment information.
  • The PREM screen can be called up by screen name with no AU or Client pointers required at the top of any ACES screen or by pressing <F20> -PREM from the MAFI screen.

The PREM screen is not benefit month driven. PREM displays the latest premium that the Head of Household must pay per month. Historical data can be viewed by using the As of Date field on AMEN, Option B - AU/Client Inquiry.


EXAMPLE

To see what premium amount was sent to Financial Services Administration (FSA) for historical benefit month 06/04,

  • In the AU ID or Client ID field enter the [Assistance Unit or Client ID]

  • Benefit Month field enter [06 04]

  • As of Date field enter [05 21 04] which is monthly issuance date for 06/04.

  • Assistance Unit >> Premium Amount >> Children’s Med page in aces.online displays Premium for Optional Medicaid information. This page can also be accessed from the Details>Assistance Unit Summary Page.

On the Welcome Back page, use the Quick Navigation section to complete the following steps:

  1. From the Select a Type of ID drop down box, click Assistance Unit.
  2. Enter the Assistance Unit number you want to view the Premium information on in the Enter an IDfield.
  3. From the Select a Page drop down box, click Premium Amounts – Children’s Med.
  4. Click on the Go button. The Premium Amount – Children’s Med displays.

Advance Notice for Premium Amount Changes

  • 10-days advance and adequate notice is required when a household’s premium responsibility begins or changes due to a change in an active Assistance Unit. For any adverse action a 10-day effective date is calculated on PREM. The client’s premium changes the first of the month following the month listed in the Premium Effective Date field on PREM. The 10-day adverse action premium effective date cannot be waived. If a change is made before the end of the month, with less than 10-days advance and adequate notice (adverse action) the premium responsibility will start the following month.
     

EXAMPLE

If a change to reduce the household premium from $15 to $10 is processed on 6/24/04, the amount is changed on PREM to $10 in the Premium Amount field, with a Premium Effective Date of 6/24/04. A $10 July 2004 premium amount is passed to Financial Services Administration (FSA) through an interface.

EXAMPLE

On 6/24/04 a household, with a mandatory child, reports their family income has increased. The increased income changes the child’s eligibility to non-exempt and optional. The family is required to pay a $10 premium. By processing this change on 6/24/04, there is not sufficient time to allow 10-days advanced notice before the end of the month. Therefore, the first month the family is required to pay a premium is August 2004. The Premium Effective Date on PREM is entered as 7/04/04 (10 days from 6/24/04).

Opting out Optional Child

  • To opt out a child from Premiums for Optional Children the Financial Responsibility code SC – Child used to determine family size is used. The Financial Responsibility code SC includes the client when determining the FPL (Federal Poverty Level) standard for household size, but will not count the client's income in the calculation. The SC child does not receive medical benefits.

Delinquent Premium

  • When notification is received from FSA (Financial Services Administration) that a household is delinquent in premiums, owing a 3-month balance, the following actions take place:
    • For each Active F06/F07 Assistance Unit the client is the Head of Household will be reviewed for Optional Children.
    • Each non-exempt optional child’s Financial Responsibility code is changed to IC – Ineligible Child with Reason Code 342- Termination/Denial Due to Non-Payment of Premium.
    • Assistance Units without mandatory or optional exempt children close with Reason Code 342- Termination/Denial Due to Non-Payment of Premium.
    • Active F06/F07 Assistance Units with mandatory children are sent Letter 006-08 (General Termination for an Individual).
    • F06/F07 Assistance Units that close are sent Letter 006-01 (Termination for AU).
    • Alert 416 - AU Closed By Batch. Redetermine Medical Eligibility is generated to all F06/F07 Assistance Units that closed or remained active with mandatory children.
    • A Sanction Reason field entry 200- delinquent payment amount on SANC is added to each non-exempt optional child’s data. The sanction Effective Start Date (Eff Start Dt) is set to the ongoing benefit month. The sanction End Date is set at 3-months.
    • The PREM screen Premium Amount is changed to zero, and the Premium Effective Date lists the current date.
    • The PREM screen Delinquent Amount and Notification Date is updated from the FSA interface.
  • When notification is received from FSA (Financial Services Administration) that a delinquent premium amount has been paid in full, the following automated process occurs for all F06/F07 Assistance Units with the same Head of Household:
    • Delinquent Amount on PREM screen is updated to zero.
    • Full Payment Received Date on PREM screen is updated with information received from FSA (Financial Services Administration) interface.
    • A Narrative entry is AUTO added to the Head of Household, indicating the premium payment has been paid in full with the date payment was received. The entry will appear in 'pink' when displayed on the NARR screen.
    • If delinquent payment is received after the month the delinquent payment was due, a 3-month sanction must be served before the child is reinstated to medical.
    • For all Assistance Units closed with Reason Code 342 -Termination/Denial Due to Non-Payment of Premium or 245 - No Eligible Household Members and the payment received date is within the same month the delinquent amount was reported –Alert 241 Delinquent Payment Received – Reinstate AU is generated.
    • When the Assistance Unit is re-opened or reinstated, the SANC data is kept or deleted depending on the receipt timeframe of delinquent payment.
    • For all Active Assistance Units – Recalculation of eligibility will re-determine the household premium amount for the next premium interface with FSA (Financial Services Administration).
  • A system generated Financial Responsibility code IC- Ineligible Child is used to include the client when determining household size and FPL (Federal Poverty Level) limits, but not allow the client to receive benefits with the Assistance Unit.
  • The Income from an IC- Ineligible Child does not count toward the assistance unit. The verification field must be re-confirmed at time of Eligibility Review for clients with a Financial Responsibility Code of IC- Ineligible Child.
  • Sneede-Kizer and Optional Premiums:
    • When a child or client with Financial Responsibility IC- Ineligible Child starts to receive income, a separate assistance unit should be established for the client with the income.
    • If the Sneede-Kizer client on the new assistance unit is an Optional Premium member that owes a delinquent premium amount, the AU will close because there are no mandatory clients on the Assistance Unit.
    • The SANC screen is used to determine if the non-exempt Optional children pass the premium payment test. The delinquent data on PREM is only used to calculate the penalty period.
  • Client terminated due to a delinquent payment:
    • To re-establish the client back on the Assistance Unit:
      • A Sanction Exception code is necessary on SANC  or,
      • Deletion of the Sanction Penalty End Dt if the delinquent amount is zero.
  • The Delinquent Amount remains on PREM until a 12-month period has expired or ACES is notified by FSA (Financial Services Administration) that the client has paid the outstanding amount.

Sanction Exception Code

  • Valid reasons to enter a Sanction Exception Code on SANC screen are:
    • Continuous medical eligibility pending a fair hearing or
    • Department error
  • There are three Sanction Exception Code values:
    • FH - Fair Hearing
    • DE - Departmental Error
    • MD - Mandatory (Occurs when an IC-Ineligible Child changes to mandatory during a penalty period.)
  • If a penalty period must be re-established (i.e. withdrew fair hearing request), delete the Sanction Exception reason on the SANC screen for the client and confirm eligibility.
    • Valid Reason to Delete the Sanction data:
      • Client Financial Responsibility Code remained IC- Ineligible Child after a 12-month write-off and the client requests to be added back to the Assistance Unit, or
      • Any other allowed reasons where the delinquent amount is zero.
  • Clients that are in a three-month Penalty Period that have not paid their delinquent premiums will remain ineligible until the Sanction Exception Cd is entered or Sanction data is deleted on the SANC screen.

Premium Letters

  • Letter 002-10 – Approval for Family Medical
  • Letter 002-12 – Approval CN/MN Medical – No Spenddown
  • Letter 027-01 – Cash/Medical/Food Recertification and
  • Letter 021-02 – General Reinstatement for Cash/Medical/Food

Text added to include monthly premium and date the premium responsibility begins for the non-exempt optional child(ren) with Financial Responsibility code RE - Recipient.

  • Letter 008-07 – Change in Medical Premium Amount

Letter generated when the Categorically Needy Program (F06) or Children’s Health Insurance Program (F07) client has a mandatory child that becomes optional, or the income of the Assistance Unit results in a premium change.

Letter includes the monthly premium and the date the premium responsibility begins for the optional children with Financial Responsibility code RE - Recipient.

Reports

  • Three Optional Premium reports display in aces.online:
    • ACES Monthly Report of Premium Data for Active Children
    • Reopened F06/F07 Aus Bypassing Non-Payment of Premium Edits
    • Children Ineligible for Medical Due to Non-Payment of Premiums
       

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Modification Date: April 14, 2008
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