Purpose: This section will assist in determining eligibility for the Children’s Mental Health Waiver.
Current Policy Effective Date: April 1, 2010
Date Last Reviewed: January 27, 2010
Previous Policy: January 1, 2010
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POL M1002C: Determining Eligibility for Children’s Mental Health Waiver
1. Applicants Must Meet Basic Eligibility
Refer to Section M600 for basic eligibility factors.
2. Applicants Must be Age Four Through Age 20
3. Applicants Must Meet Clinical Eligibility
The Wyoming Department of Health (WDH), Mental Health and Substance Abuse Services Division determines clinical eligibility. The WP11 form verifies clinical eligibility and the waiver opening.
4. Applicants Must Meet Income Requirements
Require countable income to be within the maximum income standard per month; refer to Medicaid Table 1A. Refer to Section M901 to determine if income is countable.
5. Applicants Must Meet Resource Requirements
Require the countable resources to be within the maximum limit; refer to Medicaid Table 7. Refer to Section M801 to determine if resources are countable.
6. Services Withheld for Resource Transfers
Resources cannot be transferred for less than fair market value during the look-back period prior to application or during a period a client is receiving benefits.
Refer to Section M803 to determine if a resource transfer is exempt and to Section M804 for information on related penalties.
7. Applicants May Have Eligibility for 12 Continuous Months
The eligibility continues for 12 months from the effective date of eligibility or for 12 months from the last periodic review for applicants under the age of 19.
8. Waiver Opening Must Be Available
9. Service Start Date Provided By Mental Health Division
The Wyoming Department of Health, Mental Health and Substance Abuse Services Division will send a
WP12 form with a start date.
10. Benefits Begin First Day of Month Using Waiver Start Date
11. SSI Eligibles Do Not Need to Submit Application
Require a new application when the client becomes ineligible for SSI and re-determine eligibility.
12. Clients Must Be Reviewed
Clients must be periodically reviewed every 12 months to determine continued eligibility. Refer to Section M1403 for information on reviewing eligibility.
A review is not required for SSI clients.
13. Clients May Lose Benefits
The case will close on the first day of the next month when any of the following occur:
· Client does not complete review.
· Client dies.
· Client determined no longer eligible.
· Client enters public institution.
· Client moves out of state.
· Client’s 12-month period ends and he or she is no longer eligible.
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Reference:
Defining Group: 42 CFR 435.217
Social Security Act § 1915(c)
Clarifying Information:
1. Clients Pay No Patient Contribution.
Training Link: Not available at this time.
Worker Responsibilities:
Determining Best Estimates
1. Refer to Section M903 for information on determining best estimates.
Determining Countable Income
1. Refer to Section M901 for information on calculating income.
Determining Countable Resources
1. Refer to Section M801 to determine if resources are countable.
Calculating Resource Transfer Penalty
1. Refer to Sections M803 and Section M804 for information on resource transfers and related penalties.
Determining Eligibility for the Waiver
1. Accept the WP11 to verify clinical eligibility.
2. Screen for eligibility.
2A. Basic eligibility factors
2B. Age – Four through 20
2C. Income
2D. Resource
3. Eligible for the waiver:
3A. Pend case in EPICS.
3B. Send EPICS notice M305.
3B. Send the WP11 to the Mental Health and Substance Services Division to communicate eligibility.
4. Not eligible for the Waiver
4A. Screen for another Medicaid program,
4Ai) If not eligible for another Medicaid program, enter program type “ME SS” on SEPA screen in EPICS.
4Aii) If the child is 300% CAP, enter subtype “MK” on MERE screen in EPICS.
4Aiii) Deny case on SSRM screen in EPICS using appropriate code from Medicaid Table 15.
4Aiv) Send denial notice from Medicaid Table 16.
4Av) Send the WP11 to the Mental Health and Substance Abuse Services Division to communicate the reason for denial.
Authorizing Eligibility for Applicants with Waiver Start Date
1. Accept the WP12 from Mental Health and Substance Abuse Services Division to verify waiver start date.
2. Enter program type “ME SS” on SEPA screen in EPICS.
3. If the child is 300% CAP, enter subtype “MK” on MERE screen in EPICS.
4. If the child is SSI eligible, enter subtype “MC” on MERE screen in EPICS.
5. Authorize on the SSRM screen in EPICS beginning with first day of the month of the waiver start date.
6. Send approval notice M181.
7. Send the WP12 to the Mental Health and Substance Abuse Services Division to communicate the Medicaid start date.
Determining Continued Eligibility if Client Loses SSI
1. Continue Medicaid benefits for a child under age 19 for 12 months from the effective date of eligibility or 12 months from the last periodic review.
2. Require an application to determine continued eligibility when the individual is over the age of 19.
3. Enter “OU” on SEPA screen in EPICS on SSI case.
4. Open a new case in EPICS when eligible.
Discharge or Withdrawal from the Waiver
1. Accept the WP13 as notification of discharge or withdrawal from the waiver.
2. Continue Medicaid benefits for a child under age 19 for 12 months from the effective date of eligibility or 12 months from the last periodic review.
2A Send the WP13 back to the Mental Health and Substance Abuse Services Division with a Medicaid end date.
3. Screen for another Medicaid program when the individual is over age 19.
3A. If not eligible for another Medicaid program, close case on the SSRM screen in EPICS, using appropriate code from Medicaid Table 15.
3B. Send 10-Day closure notice from Medicaid Table 16.
3C. Send the WP13 back to the Mental Health and substance Abuse Services Division with a Medicaid end date.
Reviewing Cases
1. Refer to Section M1403 for information on reviewing cases.
Closing Cases
1. Close case on SSRM screen in EPICS for the appropriate benefit month, using appropriate code from Medicaid Table 15.
2. Send 10-Day closure notice from Medicaid Table 16 when an adverse action has occurred.
3. Send the WP16 to the Mental Health and Substance Abuse Services Division.