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IMA POLICY MANUAL
PART I: INTRODUCTION
ACEDS MA Program Types 2.2.2
Within the Automated Client Eligibility Determination System (ACEDS), there are six MA program types. These program types can be thought of as groupings of the eligibility criteria described in Section 2.2.1: MA Program Types in this Chapter. The following table shows how the eligibility criteria correspond to the MA program types.
AR
(This code was not changed when Aid to Families with Dependent Children (AFDC) was replaced by TANF.) |
- TANF Standard
- Foster Care/Department Ward/Adoption Assistance Recipient
- Medically Needy Families and Children
- Poverty Level Families and Children
- Transitional Medicaid
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| AX |
- Children with Other Health Insurance
- D.C. Healthy Families Expansion Group for Children (CHIP)
- D.C. Healthy Families Expansion Group for Parents/Caretaker Relatives
MA eligibility for non-elderly parents, caretakers, and children must be tested under AR criteria before being tested under AX criteria. If a child, parent, or caretaker relative is ineligible for MA under any AR criteria except Transitional Medicaid, the Department must then determine if they meet AX eligibility. |
| SR |
- SSI Recipients
- Aged/Disabled
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| QM |
- QMB (Most QMBs are also eligible for Medicaid based on the Aged/Disabled category. Individuals eligible for Medicaid under the Aged/Disabled category and Medicare Buy-In are processed under the SR program type.)
- SLIMB (Note that effective July 1, 2005, SLIMB eligibility applies only to the month of application and the three months prior to the month of application, since the QMB income limit has been increased to include these customers for the period beginning with the month following the month of application.)
- QI-1 (Note that effective July 1, 2005, there are no QI-1 eligible customers, since the QMB and SLIMB income limits have been increased to include these customers)
- QDWI
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| RR |
- Refugees, asylees, and certain other immigrants in their first eight months in the country
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| LT |
- Individuals in a LTC facility
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MC
(This code was not changed when Medical Charities was phased out.) |
- Previous “Medical Charities” program type. It is now used for 1115 (50-64) Demonstration that serves District residents age 50 to 64 who meet Medically Needy financial eligibility requirements. Effective June 1, 2006, it is also used for the DC Healthcare Alliance (See Part VII, Chapter 4: "DC Healthcare Alliance Program.)
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Individuals eligible for emergency Medicaid services only are assigned the program type that they would have been in had they not been ineligible due to immigration status. These individuals receive a separate code that indicates they are eligible for emergency services only.
The SSR should encourage individuals applying for and/or qualifying for MA under SR to apply for SSI at a Social Security Office. The SSR should explain that since SR MA uses the same income, asset, and disability standards as SSI, individuals eligible under SR are likely to be SSI-eligible. The SSR should inform individuals qualifying for SR of the benefits of receiving SSI (i.e., cash assistance to meet basic needs and no need to recertify Medicaid eligibility as long as they continue to receive SSI).
Determining MA Eligibility 2.2.3
The SSR must determine the ACEDS MA program type, using the following guidelines, under which each applicant may be potentially eligible for MA:
- SSI recipients are always in an SR unit.
- TANF recipients are always in an AR unit.
- MA eligibility for parents, children, and caretaker relatives is always tested under the AR program type before the AX program type.
- Parents, caretaker relatives, and children ineligible for MA through the AR or SR types should be tested under the AX type.
- If a child is not receiving SSI but could qualify as either an SR or AR/AX case, the SSR should initially evaluate the child as an AR/AX case because this does not require a disability determination.
- If a parent or caretaker relative is not receiving SSI but could qualify as either AR/AX or SR, the SSR should:
- initially evaluate the parent/caretaker relative as an AR or AX (whichever is appropriate given his/her income), and
- explain that if s/he returns the completed medical evaluation form, and is determined to be disabled by the Medical Review Team, s/he will not be placed in managed care.
While SSRs must select the ACEDS MA program type under which MA eligibility will be tested, ACEDS will determine the income category in which an individual fits if the individual is eligible for MA within the SSR-selected program type.
| Ms. Lee and her two pre-school children (under the age of 6) apply for MA. The family does not receive TANF. The family's net income is 130 percent of the FPL. The SSR should put all three individuals in the assistance group and select program type AR. After the family's income and other information has been entered, ACEDS will determine that the children are eligible for MA under the Poverty Level Children and Pregnant Women criteria. Ms. Lee, however, is ineligible for MA as part of an AR unit because her income is too high. The SSR should now create an AX unit that includes Ms. Lee and includes provisionally the two children (the children will remain in the AR unit, but they must be included provisionally in the new AX unit so the income eligibility limit for Ms. Lee will reflect 200 percent of the FPL for a family of three). Since the AX unit meets the D.C. Healthy Families Expansion Group for Parent/Caretaker Relatives eligibility criteria, ACEDS will find Ms. Lee eligible for MA as an AX unit. |
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