The system will now alert the caseworker to conduct an ex-parte review thirty (30) days in advance of the closing or conversion.  It will generate a pre-closing review letter for those individuals losing eligibility because the twelve (12) month time limit has expired.  The system will continue to close or convert TMA recipients to Extended Transitional Medical Assistance (ETMA) based on the insured status if other eligibility is not found during the ex-parte or pre-closing review.

I. Ex-Parte Review

The following reports will be produced thirty (30) days in advance of the end of the TMA period.

FIM31417-01 TMA Cases to Convert to ETMA Effective (mm/dd/yy)

FIM31419-01 TMA Cases to Close Effective (mm/dd/yy) This report will include TMA cases that will be closing at the end of six (6) months for failure to return a quarterly report.    There is an indicator of whether it is a six (6) or (12) month closing.

These reports will list all active persons on the case.  Staff must review each individual’s possible eligibility under other MC+/Medicaid categories.  Determine eligibility using information from the record and other available records, i.e., Food Stamp or Childcare records, SDX, IIVE, IMES, etc.  Any children active on these cases should be moved to MC+ for children. 

A. Action Necessary for 12 Month Closings:

Explore eligibility for Medical Assistance for Families (MAF). Use the information from the last quarterly report, if available, to evaluate eligibility.  It is not necessary to explore eligibility under the Custodial Parent or Non-Custodial Parent programs because the parents are insured.  If eligible, close the TMA and approve MAF effective the first of the following month.  Use the IM-33MCC to notify the client of the change in eligibility.

B. Action Necessary for 6 Month Closings:

Explore eligibility under MAF.  If ineligible, evaluate eligibility for Custodial Parent if uninsured.  If eligibility is established, use the IM-33MCC to notify the client of the change in eligibility.  If eligibility is not found as a result of the ex-parte review, or there is insufficient information available to determine eligibility, allow the case to close at the end of the original six (6) month time limit.  The system generated IM-57 (Transitional Medical Assistance Closing Notice) notified the family that TMA coverage will end.

Example:  Mrs. T. reported new employment but failed to provide wage verification.  She was switched to TMA, as it could not be established she continued to qualify for MAF as we were unable to obtain any wage information.  She failed to return her quarterly report.  When she appears on the list, there is not enough information in the case file to determine other eligibility.   Check IMES and all other available sources of information.  If no information can be found, allow the system to close the case. 

C. Action Necessary for Cases Due to Convert to ETMA:

Explore eligibility for MAF. It is not necessary to explore eligibility under the Custodial Parent or Non-Custodial Parent programs for cases converting to ETMA, as ETMA has an equal benefit package and higher income limits.  If ineligible for MAF, allow the uninsured TMA recipient to convert to ETMA.  A systems generated letter will advise the client of the change to ETMA.

If MAF eligible, close the TMA and approve MAF effective the first of the following month.  Use the IM-33MCC to notify the client of the change in eligibility.

II. Pre-Closing Review

A system generated notice of ineligibility for TMA will be sent thirty (30) days in advance of twelve (12) month eligibility period ending.  There are three (3) versions of the notice,

• one for recipients who will convert to ETMA as uninsured (IM-80PRE (S8)),
• one for TMA cases that will close as insured where there are children active on the case (IM-80PRE (S7)), and
• one for TMA cases that will close as insured where there are no children active on the case (IM-80PRE (S6)). 

These notices will inform the recipients that eligibility for MAF is being explored.  The notices also inform recipients of other possible basis for eligibility and serves as the Pre-Closing Review Notice (See attached).  The individual will be allowed ten (10) days to respond.

The letter to a recipient not eligible for ETMA because of insured status advises our records reflect health insurance coverage and if this is incorrect, to notify our office as this could affect their eligibility.  If the client reports the health insurance coverage is no longer in effect, update Field 13-03 to reflect uninsured status immediately and submit a TPL-1 to Division of Medical Services notifying them of the change.

A. No Response from Client

If eligibility is not established in the ex-parte review and there is no response from the individual indicating any other possible basis for eligibility, allow the case to close or convert to ETMA as appropriate.  A system generated closing or conversion to ETMA letter will be sent (See attached IM-33MCC (S6), IM-33MCC (S7), and IM-33MCC (S8)).

B. Response from Client:

If eligibility is not established in the ex-parte review but the individual responds to the Pre-Closing Review Notice indicating other possible eligibility, register the appropriate application (MA, MPW) in IAPP. 

Allow the current TMA eligibility for the individual due to close because of insured status to remain open pending the eligibility determination for the other category.  This is done by updating the IMU5 with case action 29, re-enter reason for closing and entering a new date in Field 32 of three (3) months in the future.  This action will prevent the system from closing at the end of the original time limit. 

Uninsured individuals indicating other possible eligibility should be allowed to convert to EMTA at the end of the original time limit.

If the client notifies the worker of a change in circumstances such as a change in income, re-evaluate eligibility for MAF.

No new, signed application from the individual is required to switch categories  Use the IM-2D when determining eligibility under Medical Assistance.  One category of coverage should not be stopped before the other category is approved or determined ineligible.

NOTE:  If the individual does not respond to the Pre-Closing Review Notice within ten (10) days, but does respond indicating other possible eligibility prior to the termination of the TMA, follow the same instructions above.  If they respond indicating other possible eligibility after the case is closed, treat as a new application.  If the case converted to ETMA, switch categories if or when other eligibility is established.

1) Eligibility Established for Another Category

If a recipient converted to ETMA is found eligible for a new category as a result of the pre-closing review, close the EMTA and approve the other category retroactive to conversion to ETMA if eligibility exists.

If the TMA recipient who did not convert to ETMA is found eligible for another category as a result of the pre-closing review, close the TMA and approve the other case same date effective with the first of the following month. 

Use the IM-32 to notify the client of approval for MA.  Use the IM-33MCC to notify the client of approval for MC+ for Pregnant Women and include information about the ending date of post-partum coverage.  Each notice should include a statement that eligibility is no longer established under TMA or ETMA and the reason.

NOTE:  When there are two parents on the TMA case and eligibility is established elsewhere for one parent, the other may continue on EMTA.

2) Ineligible for Another Category

TMA Closing Ineligible for ETMA: If determined ineligible based on reported pregnancy, disability, blindness or change in circumstances, send an MC+ Advance Adverse Action Notice 
(IM-80MC) specifying the reason eligibility for MC+/Medicaid does not exist.  Address the reason for the denial of the new category, the reason for loss of eligibility for TMA and the reason ineligible for ETMA.  A separate rejection notice for the new category is not required as the IM-80MC notifies the client of ineligibility for MC+/Medicaid categories and provides appeal rights.  The TMA case should be closed once the IM-80MC expires, as they are insured and the twelve (12) month period has ended.

Send a closing letter citing all reasons provided on the IM-80MC.

TMA Eligible for ETMA: If determined ineligible for the new category, the appropriate rejection notice should be sent to the individual.  Since the case was allowed to convert to ETMA at the end of the original time limit, no further action is required.  A systems generated letter notified the client of the conversion to ETMA. 

III. Appeals: 

If a client requests a hearing to appeal the denial of eligibility for other programs, allow the TMA case to remain open pending a decision.  Re-enter case actions 29, reason for closing, and change the date in Field 32 to a future date.

IV. Additional Reports:

The following reports have been produced for monitoring purposes:

FIM-31412-01 TMA Cases Closed Effective (mm/dd/yy) 

This monthly report will reflect only those individuals whose TMA eligibility was closed by the system at the end of the six (6) TMA period as they failed to return the quarterly report and at the end of the twelve (12) TMA period as they were insured. 

FIM-31418-01 TMA Cases Converted to ETMA Effective  (mm/dd/yy) (Uninsured)

This monthly report will reflect only those individuals who were systematically converted from TMA to ETMA during a given month.

SUPPORT-RELATED CLOSINGS:

Continue to treat support-related closings as we currently do.   Systems closings of these cases occur on the payroll closing date of the fourth month.   The children should immediately be moved to MC+ for Children and the parent placed on CP if eligibility exists effective with the first of the following month.  If insured, evaluate eligibility for other categories of assistance. 

• Review this memorandum with appropriate staff.
• Explore all other categories of assistance before allowing the TMA case to close or convert to ETMA.
• Implement these procedures upon receipt of the monthly reports.
• File copies of the letters and reports in the Forms Manual.