Article 8 Section 01 Certification

 

Table of Contents

Title

PG Cite

General

08.01.01A

Beginning Month

08.01.01B

Ending Month

08.01.01C

Automatic Extension Process

08.01.01D

CMSPG LTR 08 (01/12)

 

08.01.01 Certification

 

08.01.01A
General

This section contains guidelines for determining certification periods for CMS applications processed via a County worker at a CMS eligibility site or by an HOS worker for patients admitted to the hospital through the emergency room.

 

08.01.01B
Beginning Month

The applicant must meet all eligibility criteria before certification. The first month of the certification period depends upon when the applicant has met all eligibility criteria.

If all criteria are...

Then the certification period begins...

met for the application month,

that month.

not met until the following month,

the month following the application month.

 

Note: In the case of erroneous certification, refer to 08.02.

 

Examples:First Month of the Certification Period

Scenario 1

The applicant is admitted to the hospital on July 28 and discharged on August 5.His net non-exempt income for July exceeds the CMS income limit and his estimated net non-exempt income for August is below the CMS income limit. The beginning month of the certification period is August.

Scenario 2

The applicant is admitted to the hospital on June 15 and discharged on June 20.In June, her net non-exempt property exceeds the CMS property limit.She has thirty days from the denial notice of action to spend the excess property down to within the limit.On July 10, she provides proof that she spent the property appropriately.The beginning month of the certification period is June.

Scenario 3

The applicant received treatment at a Primary Care Clinic or Hospital Emergency Room on June 15. He had no current CMS eligibility at the time the treatment was provided but is now requesting CMS coverage for that uncertified visit. If within 30 days from the date of the uncertified visit, the applicant contacts the ASO to schedule the CMS intake interview and if all other eligibility factors are met, the beginning month of the certification period is June. If the phone call was made more than 30 days from the date of the uncertified visit or if patient does not meet all other eligibility factors for the month of the uncertified visit, the beginning month of eligibility is the month of July. Refer to 02.01 for additional information.

 

08.01.01C
Ending
Month

The standard certification period for applicants is for up to six months.When a foreseeable change in circumstances that affects eligibility is expected during the certification period, the certification period may be less than six months. The last month of the certification period is the last month when all eligibility criteria are met.

 

When the certification period is less than six months, the worker must state the reason in the case record comments and on the NOA that certifies CMS.

 

Examples:Certification Period Ending Month

Scenario 1

The applicantís net non-exempt income is below the income limit in the month of application but itís expected to exceed the income limit the following month. The certification period is one month.

Scenario 2

The applicantís INS document expires in three months.The certification period is three months.

Scenario 3

The applicant needs to see a doctor or fill a prescription within 72 hours and is unable to get a bank statement.The worker can call the bank to verify the account balance and certify one month.Upon receipt of the bank statement, the worker may extend the certification period.

Scenario 4

The applicant applies in the month of May and is receiving bi-weekly gross earned income of $595. Based on the paydays, the applicant will receive two paychecks per month for the period of May through August and will get a third paycheck in September. The gross income totals $1,289.36 when converted to a monthly amount using the 2.167 factor. The net non-exempt income is $1,199.36 after deducting the $90 standard work expense, which puts the applicant over the CMS MNL. The worker will re-compute eligibility using the actual income of $595 x 2 paydays in the month. This equals a net countable income of $1,100 after deducting the $90. The worker will certify for the months of May through August.

 

MPG Letter #699 (2/09)

 

08.01.01D Automatic Extension

Individuals who have been certified CMS with the standard certification period ofup to six months and have been identified later during their certification as having a chronic condition by the ASO based on established criteria, will be evaluated to have their certification periods automatically extended up to an additional 6 months.The total certification period shall not exceed 12 months.

 

The ASO shall send a list of beneficiaries who have been identified as having a chronic condition on a monthly basis to the Health Coverage Access (HCA) designated eligibility staff.

 

HCA will evaluate ongoing eligibility and extend CMS certifications, as appropriate, by:

 

Step

Action

1

Clearing the list and identifying beneficiaries eligible for an extension and verifying that the CHRONIC indicator has been placed in IDX.

2

Extending the identified CMS benefits for up to an additional 6 months or as appropriate for a maximum total of up to 12 months, making sure to select Auto Extension indicator in AuthMED.

3

Sending Automatic Extension NOA CMS-41.

 

CMSPG LTR 08 (01/12)