Medical Extensions
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Medical Extensions

Revised April 29, 2013

Purpose: This category describes the extended medical benefits available when a family is no longer eligible for TANF cash benefits (F01) or for family medical program (F04) due to increased earnings or collection of child or spousal support.
WAC 182-523-0100Medical extensions--Eligibility.
WAC 182-523-0110Medical extensions - Reporting requirements.
WAC 182-523-0120 Medical extensions - Premium requirements.
WAC 182-523-0130Medical extensions - Redetermination.

Client Premium Issues

DO NOT REFER CLIENTS TO Financial Services Administration (FSA) OR TO THE Health Care Authority (HCA) 1-800 PHONE LINES.  All premium-related issues are a condition of eligibility and can't be resolved outside of the CSO.

Current premiums and bill information can be found in ACES Online.

  • Select the newest CN 12 month extension (F02) AUID and open it.
  • Select Details and Premium Payment Status from the list.

For history of premiums go to FSA online at http://fsa.dshs.wa.gov/reporting/default.asp.

  • Your Windows login and password is used for access if you already have access.
  • If you don't currently have access, you'll need to request security access by selecting "Click Here" and completing the required fields.  You will be sent notification by email when access is granted.

WAC 182-523-0100

WAC 182-523-0100

Effective July 1, 2012

WAC 182-523-0100 Medical extensions--Eligibility.

  1. A family who received temporary assistance for needy families (TANF) or family medical program in any three of the last six months in the state of Washington is eligible for extended medical benefits when they become ineligible for their current medical program because the family receives:

    1. Child or spousal support, which exceeds the payment standard described in WAC 388-478-0065, and they are not eligible for any other categorically needy (CN) medical program; or 

    2. Increased earned income, resulting in income exceeding the CN income standard described in WAC 388-478-0065. A family is eligible to receive extended medical benefits beginning the month after termination from TANF cash or family medical program for:

    1. Four months for a family described in subsection (1)(a) of this section; or

    2. Up to twelve months, in two six-month segments, for a family described in subsection (1)(b) of this section. For the purposes of this chapter, months one through six are the initial six-month extension period. Months seven through twelve are the second six-month extension period.

  3. A family member is eligible to receive six months of medical extension benefits as described in subsection (2)(b) of this section unless:

    1. The individual family member:

      1. Moves out of state;

      2. Dies;

      3. Becomes an inmate of a public institution;

      4. Leaves the household; or

      5. Does not cooperate, without good cause, with the division of child support or with third party liability requirements.

    2. The family:

      1. Moves out of state;

      2. Loses contact with the department or the department does not know the whereabouts of the family; or

      3. No longer includes a child as defined in WAC 388-404-0005(1).

  4. A family member is eligible to receive the second six months of medical extension benefits as described in subsection (2)(b) of this section unless:

    1. The family is no longer eligible for the reasons described in subsection (3)(a) or (b); or

    2. The individual family member is the caretaker adult who:

      1. Stops working or whose earned income stops;

      2. Does not, without good cause, complete and return the completed medical extension report or otherwise provide the required income and child care information; or

      3. Does not, without good cause, pay the billed premium amount for one month.

  5. A family described in subsection (3) will not receive medical extension benefits for any family member who has been found ineligible for TANF/SFA cash because of fraud in any of the six months prior to the medical extension period.

  6. For the purposes of this chapter, only individual family members that are eligible for Medicaid are certified to receive medical benefits under this program.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

CLARIFYING INFORMATION

Medical Extensions

Medical extensions (ACES coverage groups F03, F10, F02) are CN medical benefits given to families who are, or who become, ineligible for TANF or Family Medial because of income from specific sources.

  • These benefits are short-term, with a specific number of eligible months.  They can't be recertified after those months end.
  • Medical Extension Benefits (MEB) apply to families with needy caretaker relatives as well as parents.  If the adult was eligible for TANF or Family Medical, rules on MEB apply.
  • MEB rules don't apply to household members who were ineligible for TANF or Family Medical due to their alien status.

Four-month medical extension (F03) - child or spousal support

F03 is a four-month extension of CN medical benefits for families who:

  • Become ineligible for the TANF cash or Family Medical programs because of the amount of child or spousal support they receive.
  • Received any combination of F01, F04, and/or F10 benefits for at least 3 of the last 6 months, and
  • Aren't eligible for any other CN medical program.

When the Division of Child Support collects child or spousal support in excess of the TANF cash grant standard for two consecutive months, ACES automatically closes the cash grant.  These families are eligible for F03.

Remember:

  • Household members receiving SFA cash or those ineligible for Family Medical (F04) benefits due to their alien status are NOT eligible to receive medical extension benefits.
  • For medical programs:
    • Child support is the child's income, not the parent's.
    • The Family may remain eligible for F04 if Sneede-Kizer is applied and the child put onto a separate F06 MAU.  Do this if it makes the family eligible for F04.
    • Code the correct amount of child support on the child's UNER screen.  This will ensure associated AU's such as food assistance are computed correctly.
    • Spousal support is the income of the parent and is available to all members of the assistance unit.

NOTE:

At the end of a four-month (F03) medical extension, the children are probably eligible for Apple Health for Kids.  Complete a review to see if adults could be eligible for any other CN medical program.  Consider applying Sneede-Kizer rules if the child(ren) still have child support income.  This could allow parents to continue receiving Family Medical benefits (F04).

See examples for F03 in Resources.

Categorically Needy (CN) Family Medical Extension (F10) - to enable F02 eligibility

One of the federal requirements for F02 medical extension benefits is that a family must have received Medicaid (TANF (F01) with medical or Family medical (F04)) in at least 3 months out of the last 6 months.  F10 benefits are for families who would receive F02 medical extension benefits, except that they don't meet that federal 3- out of 6-month requirement.

Families meeting all the following conditions are eligible for CN Family Medical Extension (F10) medical coverage.  They:

  • Received at least one month of F01 (TANF) or F04 (Family Medical).
  • Are ineligible for continued F01 or F04 coverage due to excess earned income.
  • Don't meet the 3- out of 6-months requirement for F02 (Categorically Needy 12-month Extension) medical coverage.

They can receive F10 benefits for either 1 or 2 months, whichever allows them to reach the required 3- out of 6-month federal requirement.  After the F10 certification ends, the family receives F02 medical extension benefit coverage.

For Examples of F10, see Resources.


Twelve-month medical extension (F02) - earned income

F02 is an extension of CN medical benefits up to 12 months (in two six-month segments), for families who:

  • Received any combination of TANF or Family medical (F01, F04, F10) in 3- out of the last 6-months, and
  • Became ineligible for F01 or F04 due to increased earnings.

See examples for F02 in Resources.


WAC 182-523-0110

WAC 182-523-0110

Effective July 1, 2012

WAC 182-523-0110 Medical extensions - Reporting requirements.

  1. The family must report family income and employment-related child care costs the family pays by the twenty-first day of: 

    1. Month four of the extension period, for months one, two, and three; and

    2. Month seven of the extension period, for months four, five, and six.

  2. Circumstances may prevent a family from meeting the reporting requirements in subsection (1) of this section. The family remains eligible for the medical extension when good cause exists. Reasons for good cause include, but are not limited to:

    1. Illness, mental impairment, injury, trauma, or stress;

    2. Lack of understanding the reporting requirement due to a language barrier;

    3. Transportation problems;

    4. Payment for work in each month of the reporting period was paid in a different month than it was earned;

    5. The client expected to be able to meet the family medical needs, but could not; or

    6. The client was given incorrect information about the reporting requirements. Refer to WAC 388-422-0020(4) and (5).

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

CLARIFYING INFORMATION

Families receiving F02 are required to report their income and employment-related childcare costs in the 4th and 7th months of certification.

  • In the middle of the 3rd and 6th months, ACES sends Letter 022-10 Medical Extension Report (MER) to the family.  The completed report is due back by the 21st day of the 4th and 7th months.
  • The completed reports detail the income and work-related childcare expenses for the previous  months.  The information in the reports establishes the amount of required premiums (if any) for the 2nd six-months of F02 benefits.

Completed MERs are timely when returned before the issuance date (deadline) of months 5 or 8.

  • Process the timely, completed MER.
  • Input the actual family earned income and employment-related childcare expenses into the ACES BPAM screen upon receipt of the MER or other sufficient information.
  • Use the first BPAM section solely for income from months 1, 2, and 3 of the certification period.
  • Use the second BPAM section solely for income from months 4, 5, and 6 of the certification period.  Correct completion of the BPAM screen is necessary to provide accurate:
    • Premium information to FSA; and
    • Notification letters to the clients.

Monthly activity time-line during the twelve-month F02 certification:

Month

Activity

1

 

2

 

3
  • ACES mails MER

4
  • Client completes and returns MER for months 1, 2, and 3
  • Worker processes completed MER, completes top ½ of BPAM screen to establish premiums for months 7, 8, and 9

5
  • ACES mails letter on premium requirement for months 7, 8, and 9 to client at ACES deadline

6
  • ACES mails MER for months 4, 5, and 6
  • FSA sends premium bill for month 7

7
  • Client completes and returns MER for months 4, 5, and 6
  • Worker processes MER, completes 2nd ½ of BPAM screen for premiums requirements in months 10, 11, and 12
  • FSA sends premium bill for month 8

8
  • Letter on premium requirement for months 10, 11, and 12 sent to client at ACES deadline
  • FSA sends premium bill for month 9

9
  • FSA sends premium bill for month 10

10
  • FSA sends premium bill for month 11

11
  • FSA sends premium bill for month 12
  • Eligibility review sent to determine eligibility for any other medical programs

12
  • Client returns completed eligibility review
  • Worker makes eligibility determination for other programs, F02 closed end of month 12

NOTE:

The BPAM should only be changed to correct income or childcare expenses entered in error.  Don't change the BPAM screen due to changes in household income or circumstances.

WORKER RESPONSIBILITIES

Effect of Changes During F02 or F03 Medical Extensions

1.  When family composition changes during the medical extension period, take the following actions:

a.  Add a family member when a person:

i.  Is born or adopted into the family; or

ii. Returns to the family and would have been a member of the medical assistance unit if the person had been in the household when the medical extension began;

b.  Remove a family member from the medical assistance unit when the person leaves the household.

2.  A family, and each individual in the family, remains eligible for the four or twelve month medical extension unless they meet the conditions described in WAC 182-523-0100  (3) or (4).

3.  If the family reports a significant decrease in income, determine if they are eligible for another CN medical program or TANF cash.  If they are, open the family on that program; an eligibility review is not needed in this situation to redetermine eligibility for medical.  If they are later terminated due to increased earnings, the family is eligible for a new extension period.  CN medical will continue until the family can meet the "three of six months" rule for the twelve-month extension (F02).  A family can receive medical extension benefits as many times as they are eligible for them.

4.  Remember, for the F02 program changes in income reported after MER months don't change the premium amount.  See WAC 182-523-0130.

5.  If the family reports the pregnancy of an adult, code the EDD into ACES to exempt the pregnant woman from the F02 premium requirement, as described in WAC 182-523-0120.

See examples of F02 and premium requirements in Resources.


WAC 182-523-0120

WAC 182-523-0120

Effective July 1, 2012

WAC 182-523-0120 Medical extensions - Premium requirements.

  1. "Countable income" means, for the purposes of determining the premium amount described in this chapter, all earned income of the adult family members, minus the amount of employment-related child care paid for by the family. The earned income of an adult, living in the household, who is financially responsible for other members of the assistance unit is included, whether or not the person is an eligible member of the assistance unit. 

  2. The department requires the family pay to premiums for medical coverage provided during the second six-month medical extension period. The premium amount is one percent of the family's average countable income rounded down to the nearest whole dollar.  This whole dollar amount is billed per adult per month.  See subsection (3).

  3. The premiums for:

    1. Months seven, eight, and nine are based solely on the average countable income received in months one, two and three of the medical extension period; and

    2. Months ten, eleven, and twelve are based solely on the average countable income received in months four, five, and six of the medical extension period.

  4. A subsequent change in income does not effect the premium amount described in subsection (2) and (3) of this section.

  5. When a family's premium is one month in arrears, the family is ineligible for the balance of the medical extension period unless good cause exists. Reasons for good cause include, but are not limited to:

    1. Illness, mental impairment, injury, trauma, or stress;

    2. Lack of understanding the premium payment requirement due to a language barrier;

    3. Transportation problems;

    4. Non-payment of thepremium because the client expected to be able to meet the family medical needs, but could not; or

    5. Receipt ofincorrect information or non-receipt of advance and adequate notice about the premium payment requirements. [Ed. note:  the following is an incorrect WAC reference] Refer to WAC 388-422-0020(4) and (5).

  6. The department exempts individual family members from the premium requirements, as follows:

    1. Children;

    2. Pregnant women;

    3. American Indians and Alaska Natives; and

    4. Caretaker adults in a family whose countable income is equal to or less than one hundred percent of the Federal Poverty Level based on family size as described in WAC 388-478-0075(2).

  7. When determining the exemption described in (6)(b), the premium exemption is effective the first of the month following the client’s report of the pregnancy to the department.

  8. When determining the exemption described in (6)(d), the department shall include in the household size an unborn child and a person who is financially responsible for other members of the assistance unit, whether or not the person is an eligible member of the assistance unit. A person receiving SSI cash assistance is not included when determining the household size.

  9. The department determines a family's exemption from the premium requirement as described in subsection (6)(d) for:

    1. Months seven, eight and nine based solely on information available to the department at the time the premium for these months is calculated; and

    2. Months ten, eleven, and twelve based solely on information available to the department at the time the premium for these months is calculated.

  10. Any change resulting in an individual meeting the exemption criteria in subsection (6)(d) after the establishment of the premium amount for months seven, eight and nine is used to calculate the premium amount for months ten, eleven, and twelve.  Any change resulting in an individual meeting the exemption criteria in  subsection (6)(d) after the establishment of the premium amount for months ten, eleven, and twelve is not used to recalculate the premium amount for months ten, eleven, and twelve.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

NOTE:

A person entering or leaving the household doesn't affect the amount of the premium, once it is calculated.  See WAC 182-523-0120.

Billing MEB Premiums

  1. Financial Services Administration (FSA) bills adult family members for premiums in the second 6-month segment of F02 benefits. Around the 5th of each month, FSA sends the family a bill showing the premium amount due for the next month.  The family has until the 21st of the month to pay the premium.
  • If FSA receives the premium on time, ACES receives notification.
  • If FSA receives part of the premium, FSA notifies ACES that the full premium hasn't been paid.  This generates alert # 416, and closes the case at the end of the month the premium was for.
  • On receipt of alert # 416, the worker determines if the client had good cause for a late payment.  See WAC 182-523-0120 (5) for good cause reasons.  If good cause exists, process the MER as if it was returned timely, EXCEPT the 033-22 letter (Receipt of Medical Extension Report) must be generated manually.
  • If no good cause exists, the worker determines eligibility for any other medical programs each member of the family could receive.

2.  FSA notifies ACES when they receive a late payment for the full premium amount from a family previously closed due to non-payment.  That generates alert # 239.

  • Alert # 239 confirms the family paid the premium obligation in full.
  • On receipt of alert #239, the worker re-instates the F02 for the rest of the certification period.

WORKER RESPONSIBILITIES

  1. If you determine a client has a premium obligation for F02 coverage, explain the billing and payment process to the client.  Tell the client to pay when they receive the billing statement from FSA.
  2. If a client wants to know the amount they currently owe, give the client the amount shown in ACES.
  3. DO NOT REFER CLIENTS TO FSA OR TO THE HCA 1-800 PHONE LINES.  All premium-related issues must be resolved at the CSO.  Premium payment is a condition of eligibility.

NOTE:

If the client states they didn't get the premium bill, check for returned mail.  Undelivered premium billings are returned to the CSO, not to FSA.

FSA can only make payment arrangements for the full, billed monthly premium amount.


NOTE:

If the client lost the premium bill and asks where to send the payment, tell the client to:

  1. Make the check or money order out to DSHS.
  2. Include a statement that payment is for Medical Extension Benefit premium.
  3. Include the Client ID number for the head of household.
  4. Mail the payment to:

DSHS

Office of Finance Division

PO Box 9501

Olympia, WA  98507-9726

NOTE:
  • At this time, FSA doesn't accept electronic payments, such as a credit or debit card.
  • Payments must be mailed directly to FSA as shown above.
  • The client can't pay premiums at a CSO.

If you, the CSO worker, have questions about the refund of a prepaid premium or credit of a portion of the premium bill, you FSA contacts are:

FSA CONTACTS

E-mail address

Melody Green

 

ofrpremium@dshs.wa.gov

 


If you, the CSO worker, have questions about the program's eligibility policy, please contact your HCA regional representative.


NOTE:

Upon completion of the BPAM screen, ACES calculates the premium amount.  However, the client might not be billed for the premium amount that appears on the BPAM screen.  The following month, after monthly issuance (deadline), ACES will run eligibility.  Under that process, the household may be exempt from premium payment due to income under 100% FPL.  An individual household member may be exempt from premiums due to pregnancy or AI/AN status.  ACES will determine whether to bill one adult or two.  ACES also issues letter 33-02.  The premium amount that appears in letter 33-02 and on the MAFI screen is the amount billed by FSA.

 

  • When a MER is returned late, (received after the issuance date, or deadline, in month 5 or month 8), process it and determine if the client has good cause for a late report.  If so, follow the same process as a MER returned before issuance date, except you must generate the 33-02 letter telling the family the total premium amount, if any, or the exemptions from the premium obligation.  When the MER is processed after the ACES issuance date (deadline), the ACES system doesn't automatically send the 33-02 letter.

4.  If a client requests reinstatement of F02 and the case is closed for no MER:

  • Determine if the client had good cause.  If you can't make a decision about good cause immediately, continue medical coverage while you make the good cause decision.  Only reinstate F02 for the balance of the certification period if they had good cause for the late report.
  • Be sure the BPAM screen has accurate income and childcare expenses for the correct months in order to ensure billing the correct premium amount.
  • Send a 33-02 letter to the client to inform them of the premium amount.

5.  If a client requests reinstatement of F02 and the case closed for non-payment of premiums:

  • If you determine the client has good cause for not paying premiums that have already been billed, reinstate F02 for the balance of the certification period and contact FSA, as described above, telling them to credit that portion of the client's premium obligation.

WAC 182-523-0130

WAC 182-523-0130

Effective July 1, 2012

WAC 182-523-0130 Medical extensions - Redetermination.

  1. When the department determines the family or an individual family member is ineligible during the medical extension period, the department must determine if they are eligible for another medical program. 

  2. Children are eligible for 12 month continuous eligibility beginning with the 1st  month of the medical extension period.

  3. When a family reports a reduction of income, the family may be eligible for a family medical program instead of medical extension benefits.

  4. Postpartum and family planning extensions are described in WAC 388-462-0015.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

CLARIFYING INFORMATION

The client receives a review at the end of the medical extension certification period.  Families aren't eligible for consecutive MEB certifications.  Screen an F04 to redetermine eligibility.

When the client returns the review timely, continue CN coverage until you complete a re-determination of eligibility for all other medical programs.

ACES PROCEDURES

See Medical - Medical Extensions

Four month extension:  See Closing Assistance Unit / Client - Close an AU / Client

Transitional medical extension:  See Trickle and Sprout

Quarterly reports:  See Medical - Quarterly Reporting (QR)

Modification Date: April 29, 2013