IMA POLICY MANUAL
PART I: INTRODUCTION
Medicaid recipients (other than those in the QM group who are eligible only for assistance in paying Medicare-related premiums, etc.; see Section 2.2.1: MA Program Types in this Chapter) can access preventative, primary, acute, and chronic care services such as:
- clinic services;
- clinical psychologist services;
- dental care;
- drug and alcohol treatment;
- durable medical equipment;
- Early Periodic Screening, Diagnosis, and Treatment (EPSDT) for children and adolescents;
- emergency care;
- family planning services;
- immunizations;
- in-patient/out-patient hospital care;
- inpatient psychiatric hospital care for children and adolescents;
- labor and delivery;
- laboratory and x-ray services;
- nursing home and home health care;
- physical and occupational therapy;
- physician services;
- prenatal care;
- prescription drugs;
- school physicals; and
- vision care
Most AR/AX Medicaid recipients are required to enroll in one of the managed care organizations that the District has contracted with to provide care to Medicaid recipients. There are a few exceptions, including Foster Care/Department Ward/Adoption Assistance Recipients and HIV-infected persons. Shortly after someone is determined Medicaid eligible under AR/AX, s/he will normally be contacted by the District's Medicaid Managed Care 'Enrollment Broker.' The 'Enrollment Broker' is responsible for educating Medicaid recipients about their managed care provider options, including :
- how to make a managed care provider selection, and
- how to obtain services under a managed care delivery system.
Recipients can obtain the above listed services by visiting a managed care plan provider. However, some types of mental health services can be obtained by seeing any provider who is certified as meeting the applicable Medicaid program provider requirements and is willing to accept Medicaid payment.
Individuals eligible for emergency Medicaid services are only eligible for medical services for
a medical condition (including labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
- Placing the patient's health in serious jeopardy.
- Serious impairment to bodily functions.
- Serious dysfunction of any bodily organ or part.
Retroactive Eligibility 2.2.5
When a person applies for Medicaid, s/he can also apply for three months of retroactive eligibility. If s/he meets the financial and non-financial eligibility criteria during the three months prior to application, Medicaid will pay his/her outstanding bills from that three-month period.
Salazar Court Order 2.2.6
The Salazar court order governs how Medicaid applications filed on behalf of groups who are not categorically eligible (i.e., groups composed of TANF recipients, GC recipients, SSI recipients, children in foster care, department wards, or children receiving IV-E foster care payments or IV-E adoption assistance benefits, see Chapter 12: Categorical Eligibility in Part IV) and groups who are not applying based on disability are to be processed. It requires the following:
- Covered Medicaid applications are to be processed within 45 days;
- If an application is not processed within 45 days, the Department will automatically deem it eligible for not less than three months; and
- All recertifications must be registered in ACEDS as soon as they are received, if they are signed.
The bulk of the Manual relating to MA pertains to the following ACEDS MA program types: AR, AX, SR, and QM. Information specific to Refugee-Related Medicaid (RR program type) is located in Chapter 7: Citizenship/Alienage in Part IV and Section 1.4: Refugee Medical Assistance in Part VII). Issues related specifically to emergency Medicaid are also found in Chapter 7: Citizenship Alienage in Part IV. Policies relating to LTC Recipients (LT program type) are found in Chapter 2: Long-Term Care/Impoverished Spouse in Part VII.
Most policies relating to non-financial and financial eligibility requirements are consistent within the ACEDS program types (AR, AX, SR, and QM). Therefore, when describing MA policies that are not consistent between these program types (that is, the policy for the AR program differs from the policy in the SR program), the policies for each program type will be described.
Sometimes, MA policy is not divided between the AR and AX program types. This is because application processing rules for children, parents, and caretaker relatives do not depend on whether the family will ultimately be found eligible under the AR or AX program type but rather depend on the type of application submitted (see Part III: Application Processing). Families applying only for Medicaid can fill out the D.C. Healthy Families Application. Families applying for Medicaid in addition to TANF and/or FS must fill out the Combined Application (CA). The D.C. Healthy Families application is shorter, and families applying for Medicaid using this form are required to verify less information provided on the application. Many children and parents applying for Medicaid using the D.C. Healthy Families Application are found eligible for Medicaid under the AR program type.
In cases where the policies differ for families with children based on the type of application filed rather than on the program type under which their eligibility will be determined, the Manual uses the following groupings to distinguish between families filing a D.C. Healthy Families Application and families filing a CA: AR/AX D.C. Healthy Families Application Users, AR/AX Combined Application Users, and the other groups will remain as described above (SR and QM).
