The caseworker should authorize full Medicaid following guidance
provided in DHB Administrative Letter 09-20, Amended, Recertification
Procedures for COVID-19 and continue coverage through the end of the
PHE. Caseworkers should use the Medicaid forced eligibility application
process to reinstate full Medicaid if the beneficiary does not meet
eligibility requirements for any full Medicaid program. When keying
Medicaid forced eligibility, use the reason, COVID-19.
Example:
Sue was receiving Medicare, MAD and MQB-B. Sue received a lump-sum
settlement that put her over the reserve limit for MAD. The caseworker
terminated her MAD case May 21, 2021 however, she remained eligible
for Medicare and MQB-B. In June 2021, Sue loses her Medicare
eligibility. This does not meet MEC requirements therefore, full Medicaid
must be reinstated effective July 1, 2021. Following guidance in Amended
DHB Administrative Letter 09-20, coverage for Sue will continue with
Medicaid forced eligibility as MAD.
b. In the event that an a/b with MQB-Q/B/E only who loses Medicare, please
contact your OST for further guidance.
E. Evaluating and terminating cases authorized in error
Previous guidance advised counties that Medicaid could not be terminated, or benefits
decreased during the PHE, even if the case was authorized in error.
New guidance from CMS states that the requirement for continuous enrollment
applies only to those beneficiaries who are validly enrolled in Medicaid on or after
March 18, 2020. This applies to initial applications or recertifications that occurred
before March 18, 2020 as well as to applications or recertifications occurring during
the PHE.
When it is discovered at recertification or a reported change in circumstance that a
beneficiary has been authorized for Medicaid in error, the caseworker must evaluate
to determine if the beneficiary would be eligible based on the beneficiary’s current
circumstances.
A beneficiary is not considered validly enrolled when one of the following applies:
1. The determination of eligibility was incorrect at the time it was made due to
agency error.
2. Eligibility was erroneously given due to beneficiary fraud or abuse. Fraud or
abuse is established when the beneficiary is convicted of fraud/abuse in a
court of law. Beneficiaries convicted of fraud/abuse by a court of law are
considered to be invalidly enrolled.