Table of Contents - Louisiana Department of Health and Hospitals

Medicaid Eligibility Manual Table of Contents TABLE OF CONTENTS Preface Explanatory Notes Outline A-0000 Abbreviations/Acronyms/Definition - Outline A-0000

A-100 Abbreviations/Acronyms A-100

A-200 Definitions A-200

B-0000 Introduction - Outline B-0000

B-100 The Medicaid Program B-100

B-200 Goal of the Medicaid ** Program B-100

B-300 Medicaid B-100

B-400 100% State-Funded Medical Assistance B-100

B-500 Single State Agency B-500

B-600 Coordination of Agencies B-500

B-700 Medical Care Advisory Committee B-500

C-0000 Medical Services - Outline C-0000

C-100 General Information C-100

C-200 Service Limits C-200

C-300 Covered Services C-200

D-0000 Persons Eligible - Outline D-0000

D-100 LIFC-Related Groups D-100

D-200 SSI-Related Groups D-200

D-300 Groups Related to Either ** LIFC or SSI D-300

D-400 Groups Not Related to **LIFC or SSI D-400

D-500 State-Funded Groups D-400 Reissued May 1, 1999 1 Replacing April 1, 1992 Table of Contents "**" Text Deleted "ITALICS" Text Revised

Medicaid Eligibility Manual Table of Contents

E-0000 Category - Outline E-0000

E-100 General Information E-100

E-200 Categories of Assistance for Which E-100

** BHSF Determines Eligibility

210 Aged (A) E-210

210.1 Verification E-210

210.2 Documentation E-210.1

220 Blind (B) E-220


220.2 Documentation E-220

230 ** LIFC (formerly AFDC) E-230

230.1 Specified Age E-230

230.2 Deprivation E-230.1

230.3 Pregnancy E-230.1

231 ** Reserved

240 Disabled (D) E-240


240.2 Documentation E-240.2

250 Qualified Medicare Beneficiaries (Q) E-250


250.2 Documentation E-250

260 ** Reserved E-260

Reissued May 1, 1999 2 Replacing April 1, 1992 Table of Contents "**" Text Deleted "ITALICS" Text Revised


E-300 Categories for Which **BHSF Does Not E-300

Have Responsibility for Determining Eligibility

310 Refugees (E) E-300

320 F (06) E-300

330 I (08) E-330

340 O (15) E-330

350 V (22) E-350

F-0000 Medical Programs - Outline F-0000

F-100 Eligibility Determination Responsibility F-100

C-Related Programs F-100

SSI-Related Programs F-100

Programs Related to Both F-100

**LIFC and SSI

Programs Not Related to 2 of F-100

**LIFC or SSI

F-200 Limited Responsibility F-200

C-Related Programs F-200

SSI-Related Programs F-200

Custody-Related Programs F-200



G-0000 Application Processing - Outline G-0000

G-100 Introduction G-100

G-200 General Information G-100

G-300 Application Form G-300

G-400 Time Limits for Disposing of Applications G-400

G-500 Parish of Application G-500

510 Applicant Who Moves Out of 2 of G-500

Parish Prior to Certification

G-600 Who Can Make Application for Assistance G-600

G-700 Application Date G-700

G-800 Acceptable Application Forms G-800

810 Applicant Unable to Participate in G-810

the Eligibility Determination Process

G-900 Application Interviews G-900

910 General Information G-900

911 Management G-911

911.1 How to Evaluate G-911

Management

911.2 Sources of Verification G-911.2

911.3 Documentation Requirements G-911.2

911.4 Case Action G-911.2

920 Interviews G-920

930 Interview Sites G-930

940 Required Interview Explanations G-940



G-1000 Securing Information to Determine G-1000

Eligibility

G-1100 Cooperation G-1100

1110 Cooperation By Physically and G-1110

** Mentally Able Applicants

1120 Cooperation By LTC and Other G-1120

Applicants Unable To Participate

1130 LTC Refusal to Cooperate G-1120

1140 Failure to Cooperate G-1140

1150 Second Contact Situations G-1150

G-1200 Reserved

G-1300 Obvious Ineligibility G-1300

G-1400 Withdrawals G-1400

G-1500 Death of Applicant Before Certification G-1500

G-1600 Securing Disability Decisions for G-1600

(B and D Categories)

1610 Disability Decisions G-1610

1610.1 MEDT Package G-1610

1610.2 MEDT Decision Required G-1610.2

1610.3 MEDT Decision Not G-1610.2

Required

1610.4 MEDT Approval G-1610.4

1610.5 MEDT Denial G-1610.4

1610.6 Reconsideration of G-1610.4

MEDT Denial



1610.7 Resubmit to MEDT G-1610.7

1610.8 Reapplication after G-1610.7

MEDT Denial

1610.9 Requesting Authorization G-1610.9

For Family Practioner Exam

1610.10 SSA Certifies Applicant G-1610.9

for SSI

1610.11 SSA Denials G-1610.11

1610.12 SSI Appeals G-1610.11

1610.13 Significant Deterioration G-1610.11

in Medical Condition after

SSA Denial

1620 **Reserved

1630 **Reserved

1640 Reserved

1650 **Reserved

G-1700 Reusing The Application Form G-1700

G-1800 MAP Unit Applications G-1800

G-1900 Referrals To SSI G-1900

G-2000 Decision Notices G-1900



H-0000 Eligibility Determinations - Outline H-0000

H-100 General Information H-100

100.1 Selecting a Program H-100

100.2 Evaluation of 2 of H-100.1

Eligibility In Other Programs

100.3 Assistance/Benefit Unit H-100.3

Optional Exclusions

110 Roll-Down For C-Related Assistance H-110

110.1 C-Related Categorically H-110.1

Needy

110.2 Medically Needy H-110.1

110.3 Documentation H-110.3

110.4 Roll-Down Flowchart- H-110.4

C-Related

H-200 ** Low Income Families with Children H-200

(LIFC)

200.1 General Information H-200.1

200.2 Coverage H-200

210 ** LIFC Assistance/Benefit Unit H-210

210.1 Who Shall Be Included H-210

210.2 Who May Be Included H-210.2

210.3 Separate Assistance Units H-210.3

221 Eligibility Determination Process H-221

221.1 Determine Assistance/ H-221

Benefit Unit

221.2 Establish Categorical H-221

Requirements



221.3 Establish Non-Financial H-221

Eligibility

221.4 Establish Need H-221.4

221.5 Eligibility Decision H-221.5

221.6 Certification Period H-221.5

221.7 Notice of Decision H-221.5

230 **LIFC Minor Unmarried Parent H-230

230.1 General Information H-230



Benefit Unit

231.2 Establish Categorical H-231.2

Requirements

231.3 Establish Non-Financial H-231.2

Eligibility





232 **LIFC Maternity Home H-232

232.1 Who Shall Be Payee H-232

232.2 Income H-232

240 ** PAP H-240


240.2 Coverage H-240.1

240.3 PAP Assistance/Benefit Unit H-240.1





Benefit Unit


Requirements


Eligibility


241.5 Eligibility Decision 2 of H-241.4

241.6 Certification Period 2 of H-241.6

241.7 Notice of Decision 2 of H-241.6

H-300 CHAMP H-300

310 General Information H-300

310.1 Presumptive Eligibility (PE) H-310.1

310.2 Pregnant Women (PW) H-310.1

310.3 CHAMP Child H-310.3

311 PAP Exclusions From CHAMP H-311

320 CHAMP Presumptive Eligibility H-320


322 Application H-321

323 Eligibility Determination H-323

323.1 Pregnancy H-323

323.2 Income Unit H-323

323.3 Income Computation H-323.3

323.4 Resources 2of H-323.3

323.5 Decision H-323.5



324 Reserved

325 Referral to the ** Appropriate BHSF H-325

Office

325.1 Eligible Pregnant Woman H-325

326 ** BHSF Responsibility H-326

Upon Receipt of PE Packets

326.1 PE Packets Not Received H-326

Within Five Days

326.2 Complete PE Packet H-326

326.3 Review of Net Income H-326.2

326.4 Closure of PE and Denial 2 of H-326.3

of CHAMP Pregnant Woman

326.5 Notices 2 of H-326.5

327-329 Reserved

330 CHAMP Pregnant Woman H-330



Benefit Unit


Requirements


Eligibility





331.8 Deem Newborn H-331.5



332-339 Reserved

340 CHAMP Child H-340



Benefit Unit


Requirements


Eligibility





H-400 Deemed Eligibles H-400


410.1 Coverage H-410.1



Benefit Unit


Requirement


Eligibility





421.8 Third Party Liability H-421.7

Reissued May 1, 1999 11 Replacing November 1, 1994 Table of Contents "**" Text Deleted "ITALICS" Text Revised


H-500 Reserved

H-600 Extended Medicaid H-600



620 Disabled Adult Children (DAC) H-620




Benefit Unit


Requirement


Eligibility





630 Disabled Widows/Widowers (DW/W) H-630




Benefit Unit


Requirement


Eligibility







640 Early Widows/Widowers (EW/W) H-640




Benefit Unit


Requirement


Eligibility





650 Pickle H-650




Benefit Unit


Requirement


Eligibility







660 Disabled Widows/Widowers and H-660

Disabled Surviving Divorced Spouses

Unable to Perform Any Substantial

Gainful Activity (SGA Disabled W/W/DS)




Benefit Unit


Requirement


Eligibility




661.7 Notice of Decision H-661.5 Reissued May 1, 1999 14 Replacing April 1, 1992 Table of Contents "**" Text Deleted "ITALICS" Text Revised


H-700 SSI Retroactive Medicaid H-700


711 Notification of Applicants/ H-700

Recipients For SSI

712 Application For Retroactive Coverage H-712

713 Retroactive Certification H-712

714 Denial For SSI Because of H-712

Disability

715 Income Rejections H-715

716 Medical Card H-715



Benefit Unit


Requirement


Eligibility







H-800 Long Term Care (LTC) H-800



810.2 Medical Certification H-810

810.3 Patient Liability H-810.3

810.4 Optional State Supplement H-810.3

810.5 Categories F, V, I, and O H-810.3

820 Long Term Care - C-Related H-820




Benefit Unit


Requirement


Eligibility



821.6 Determine Patient Liability H-821.5



821.9 Post Certification H-821.9

821.10 Transfer of Case Record H-821.9

830 Long Term Care - SSI-Related H-830


830.2 CAP Rate H-830

830.3 Personal Care Needs H-830



830.4 SSI Recipients H-830.3

830.5 SSI Recipients H-830.5

Expected to be Institutionalized

for Three Months or Less



Benefit Unit


Requirement


Eligibility



831.6 Post Eligibility H-831.6

Determination




840 Medicaid Coinsurance-Medicare SNF/NF H-840




Benefit Unit


Requirement


Eligibility







H-900 Home and Community Based Services (HCBS) H-900


910.1 Coverage 2 of H-910

910.2 Medical Certification H-910.2

910.3 Cap Rate 2 of H-910.2

910.4 **Recipient Liability 2 of H-910.2

910.5 Maintenance Needs H-910.4

Allowance

910.6 Categories F, V, I, and O H-910.4



Benefit Unit


Requirement


Eligibility



921.6 ** Reserved H-921.6






H-1000 Medically Needy Program (MNP) H-1000


1010.1 Categorical Relatedness H-1000

1010.2 MNIES H-1000

1011 Groups H-1011

1011.1 Regular MNP H-1011

1011.2 Spend-down MNP H-1011.2

1011.3 Eligibility Period H-1011.3

1011.4 Limited Certifications H-1011.4

1011.5 Bills Allowed in the H-1011.5

Spend-down Process

1011.6 Bills Not Allowed in the H-1011.6

Spend-down Process

1012 C-Related MNP Caretaker Relative H-1012

1020 Regular and Spend-down Medically H-1020

Needy - C-Related



Benefit Unit


Requirement






1021.8 Form 110-MNP H-1021.8



1030 Spend-down Medically Needy H-1030

Non-LTC- SSI-Related



Benefit Unit


Requirement


Eligibility





1031.8 Form 110-MNP H-1031.8

1040 Spend-down Medically Needy H-1040

Long Term Care - SSI-Related



Benefit Unit


Requirement


Eligibility





1041.8 Form 110-MNP H-1041.5



H-1100 Qualified Medicare Beneficiary (QMB) H-1100





Benefit Unit


Requirement


Eligibility





H-1200 Qualified Disabled and Working Individuals H-1200

(QDWI)





Benefit Unit


Requirement


Eligibility







H-1300 Specified Low-Income Medicare Beneficiary H-

1300




1321.1 Determination Assistance/ H-1321

Benefit Unit


Eligibility

1321.3 Establish Need H-1321




H-1400 Reserved

H-1500 ** Continued Medicaid for LIFC Recipients H-1500



1520 Child Support **Continuance H-1523

1521 Eligibility Criteria H-1520

1522 Period of Eligibility H-1520

1523 Reasons for Ineligibility H-1520

1524 Notices H-1523



1530 Transitional Medicaid ** H-1530

1531 Eligibility Criteria H-1531

1532 Period of Eligibility H-1532

1533 Reporting Requirements for H-1533

Transitional Medicaid

1533.1 Initial Extension H-1533

(Months one through six)

1533.2 Additional Six Month H-1533

Extension

1534 Reasons For Ineligibility H-1534

1535 Notices H-1535

H-1600 ** Reserved

H-1700 Legal Aliens Not Admitted For Permanent H-1700

Residence and Illegal Aliens




Benefit Unit


Requirements


Eligibility







H-1800 Retroactive Medical Eligibility (RME) H-1800




1821.1 Certification Period H-1821

I-0000 Eligibility Factors - Outline I-0000

I-100 Age - C-Related I-0000

110 Requirement I-100

120 Verification I-120

130 Documentation I-120

140 School Attendance I-140

I-200 Assignment of Third Party Rights I-200


211 Automatic Assignment I-210

211.1 Non-SSI Applicant/ I-210

Beneficiary

211.2 SSI Applicant/Recipient I-210

212 Cooperation I-212

212.1 Good Cause for I-212.1

Non-cooperation

212.2 Informing the Applicant/ I-212.1

Beneficiary of Good

Cause Provisions

212.3 Establishing Good Cause I-212.3



213 Denial or Termination of Eligibility I-213



I-300 Citizenship/Alien Status I-300


311 Citizenship I-311

311.1 Qualified Alien I-311

311.2 Acceptable Documentation I-311.2

Of Qualified Alien Status

311.3 5-Year Ban for Qualified 3 of I-311.2

Aliens

311.4 Determine 5-year I-311.4

Limitation

311.5 Mandatory Eligibility of I-311.5

Certain Qualified Aliens

Living in the United States

Before August 22, 1996

311.6 Mandatory Eligibility of I-311.6

Qualified Aliens Entering

The United States on or

After August 22, 1996

312 Alien Status I-312

312.1 Undocumented Aliens I-312

**

313 ** Reserved

314 American Indian Born in Canada I-314

314.1 Verification I-314



315 ** Reserved

316 ** Reserved

317 Non-Qualified Aliens I-317

Eligible for Emergency Services

318 Ineligible Aliens I-318

319 Reserved



I-400 Continuity of Stay (LTC Only, Except HCBS) I-400


420 Verification 2 of I-410

430 Documentation 2 of I-410

I-500 Deprivation I-500


511 Legally Responsible Parents I-511

512 Deprivation Based on Death of I-512

a Parent

512.1 Sources of Verification I-512

512.2 Documentation I-512 Reissued May 1, 1999 26 Replacing April 1, 1992 Table of Contents "**" Text Deleted "ITALICS" Text Revised


513 Deprivation Based on Absence I-513

of a Parent

513.1 Locating and Interviewing I-513

the Absent Parent

513.2 Sources of Verification 3 of I-513.1

513.3 Documentation of I-513.2

Continued Absence

514 Deprivation Based on Incapacity I-514

514.1 Action in Incapacity Cases I-514.1

514.2 Local Office Decision I-514.1

514.3 Securing **Medical 2 of I-514.2

Documentation for

MEDT Incapacity Decision

514.4 Action on MEDT Decision I-514.3

514.5 ** Request for Medical I-514.4

Exam

514.6 ** Review of MEDT I-514.4

Decision

514.7 Refusal of Medical Treatment I-514.6

or Rehabilitation

514.8 Resubmitting Form ** MEDT I-514.6

After Appeal Decision



515 Deprivation Based on Unemployment I-515

of the Parent

515.1 Establish the Principal I-515

Wage Earner (PWE)

515.2 Unemployment of the PWE I-515.2

515.3 Refusal of Employment I-515.3

515.4 Recent Connection With I-515.3

the Labor Force

515.5 Receipt of Unemployment I-515.5

Compensation Benefits (UCB)

515.6 Presumed UCB Eligibility I-515.6

515.7 Work History Requirement I-515.7

515.8 SSA "Quarters of Coverage" I-515.8

515.9 Unemployment Compensation I-515.8

Benefits (UCB)

515.10 Registration With I-515.10

Employment Security

515.11 Employment Registration I-515.10

Exemptions

515.12 Verification of Earned I-515.12

Income

I-600 Enumeration I-600




I-700 Reserved



I-800 Home I-800


811 Temporary Absence From Home I-800

812 Assistance For Homeless Families I-811



I-900 Institutionalization I-900


920 Institutions I-920

930 Inmate Status 2 of I-920

940 End of Inmate Status 3 of I-930



I-1000 Medical Certification (LTC and HCBS Only) I-1000


1011 Level Two Screening I-1000



I-1100 Medicare Ineligibility I-1100




Reissued May 1, 1999 29 Replacing August 1, 1994 Table of Contents "**" Text Deleted "ITALICS" Text Revised


I-1200 Mother's Medicaid Eligibility I-1200

(Deemed Eligible Children Only)




I-1300 Reserved

I-1400 Need I-1400

1410 General Information I-1400

1411 Need - Prohibited AFDC I-1411

Provisions (PAP)

1411.1 Alien Sponsor I-1411.1

1411.2 MUM's Parent I-1411.2

1411.3 Siblings I-1411.3

1411.4 Stepparent I-1411.4

1411.5 Caretaker Relative I-1411.5

1420 Need - Deeming I-1420

1421 Definitions for Deeming Purposes I-1421

1422 When Deeming Is Not Applicable I-1422

1423 Deeming of Resource I-1423

1423.1 Resources Excluded From I-1423

Deeming

1423.2 Parent To Child I-1423.2

Resource Deeming Procedure

1423.3 Sponsor To Alien Resource I-1423.2

Deeming Procedure



1424 Deeming of Income I-1424

1424.1 Income Not Included I-1424

In Deeming

1424.2 Income Deeming Procedures I-1424.1

I-1500 Need - Income I-1500


1510.1 Income Standards I-1501.1

1510.2 Ownership of Income I-1510.2



1520 Need - C-Related Income I-1520

1521 Income Unit I-1520

1522 Reserved

1523 Reserved

1524 Types of Income (C-Related) I-1524

1524.1 Adoption Assistance - I-1524

AFDC-M and AFDC-PAP Only

1524.2 Agent Orange Settlement I-1524

1524.3 Agriculture and Stabilization I-1524

and Conservation (ACSE)

Payments

1524.4 Alien Sponsor's Income I-1524

1524.5 Alimony I-1524.5

1524.6 Cash Contributions I-1524.5

1524.7 Child Care Program I-1524.7



1524.8 Child Support I-1524.7

1524.9 Child's Earned Income I-1524.7

1524.10 Contractual Income I-1524.9

1524.11 Delta Service Corps I-

1524.10

1524.12 Disability Insurance Benefits I-1524.11

1524.13 Disaster Payments I-

1524.11

1524.14 Dividends I-1524.11

1524.15 Domestic Volunteer I-1524.15

Service Act

1524.16 Earned Income Credits I-1524.15

(EIC)

1524.17 Education Assistance I-1524.15

1524.18 Energy Assistance I-1525.17

1524.19 Foster Care Payments I-1524.17

1524.20 Housing and Urban I-1524.17

Development (HUD) Payments

1524.21 Indian and Native Claims I-1524.21

and Lands

1524.22 In-Kind Income I-1524.21

1524.23 Interest I-1524.21

1524.24 Irregular and I-1524.24

Unpredictable Income

1524.25 Job Training Partnership I-1524.25

Act of 1982 (JTPA)

1524.26 Loans 2 of I-1524.25

1524.27 Lump Sum Payments 2 of I-1524.25 Reissued May 1, 1999 32 Replacing April 1, 1992 Table of Contents "**" Text Deleted "ITALICS" Text Revised


1524.28 Military Pay and

Allowance 3 of I-1524.27

1524.29 Minor Unmarried Mother's I-1524.29

(MUM) Income

1524.30 Nutrition Program I-1524.29

1524.31 Oil and Land Lease I-1524.31

1524.32 Pensions and Annuities I-1524.31

1524.33 Potential Income I-1524.31

1524.34 Radiation Exposure I-1524.34

Compensation Payments

1524.35 Railroad Retirement I-1524.34

1524.36 Reimbursements I-1524.34

1524.37 Relocation Assistance I-1524.34

1524.38 Rental Property I-1524.38

1524.39 Resource Granny I-1524.38

1524.40 Retirement I-1524.38

1524.41 Roomers/Boarders I-1524.38

1524.42 Royalties I-1524.42

1524.43 Self-Employment Income I-1524.42

1524.44 Social Security (RSDI) 3 of I-1524.43

1524.45 Stepparent=s Income I-1524.45

1524.46 Summer Youth Employment I-1524.45

Program (SYEP)

1524.47 Supplemental Security I-1524.45

Income (SSI)

1524.48 Tax Refunds I-1524.45



1524.49 Trust Funds I-1524.49

1524.50 Tutorship Funds I-1524.49


Benefits (UCB)

1524.52 Vendor Payments I-1524.49

1524.53 Veteran=s Administration I-1524.53

Benefits

1524.54 Wages, Salaries, and I-1524.53

Commissions

1524.55 Wartime Relocation of I-1524.53

Civilians= Payments

1524.56 Women, Infants and I-1524.56

Children=s (WIC) Program

1524.57 Work Study I-1524.56

1524.58 Workmen=s Compensation I-1524.56

1525 Need - C-Related Treatment I-1525

Of Income

I-1525.1 185% Pretest I-1525.1

I-1525.2 Rounding Procedures I-1525.2

1526 Deductions I-1526

1526.1 Standard Earned Income I-1526

Deduction

1526.2 Earned Income Exemption I-1526.2

(EIC)

1526.3 Dependent Care Deduction I-1526.3

1526.4 Court-ordered Child Support I-1526.3

And/or Alimony to Persons

Outside the Home Reduction



1527 Need - C-Related - Budgeting of I-1527

Income

1527.1 Budgeting in LIFC for I-1527

Stepparent or Spouse of a

Qualified Relative

1527.2 Budgeting Income From the I-1527.2

Parents of a MUM or Pregnant

Unmarried Minor

1527.3 MUM's Parents Budgeting I-1527.3

in **LIFC

1527.4 MUM's Parents Budgeting I-1527.3

in C-MNP and CHAMP

1527.5 Pregnant Minor's Parents I-1527.5

Budgeting in **LIFC,

**PAP, and C-MNP

1527.6 Pregnant Minor's Parents I-1527.5

Budgeting in CHAMP

1528 Allocation of Income in C-Related I-1528

1530 Need - SSI-Related Income I-1530

1531 Income Unit I-1530

1532 Potential Income (Applying for I-1532

Other Benefits)

1533 Reserved

1534 Types of Income (SSI-Related) I-1534

I-1534.1 Agent Orange I-1534

Settlement Payments



1534.2 Adoption Subsidy I-1534

1534.3 Agriculture and Stabilization I-1534.3

And Conservation Payments

1534.4 Alien Sponsor=s Income I-1534.3

1534.5 Alimony I-1534.3

1534.6 Annuity I-1534.6

1534.7 Assistance Based on Need I-1534.6

1534.8 Black Lung Disease Benefits I-1534.6

1534.9 Capital Gains Distribution I-1534.6

1534.10 Cash and In-Kind Replacement I-1534.10

Items

1534.11 Child Care Food Program I-1534.10

Payments

1534.12 Child Support I-1534.10

1534.13 Commissions I-1534.13

1534.14 Community Spouse=s Income I-1534.13

1534.15 Contractual Income I-1534.13

1534.16 Contributions I-1534.13

1534.17 Death Benefits I-1534.13

1534.18 Disability Payments 2 of I-1534.17

1534.19 Disaster Assistance I-1534.19

1534.20 Dividends I-1534.19

1534.21 Domestic Volunteer Service

Act I-1534.21

1534.22 Donations I-1534.21

1534.23 Earned Income Tax Credits I-1534.23

(EITC)

1534.24 Educational Assistance (Grants,I-1534.23

Scholarships, Fellowships) Reissued May 1, 1999 36 Replacing April 1, 1992 Table of Contents "**" Text Deleted "ITALICS" Text Revised


1534.25 Energy Assistance I-1534.23

1534.26 Fellowships I-1534.23

1534.27 Foster Care Payments I-1534.27

1534.28 Grants I-1534.27

1534.29 Home Produce for Personal I-1534.27

Consumption

1534.30 Housing Assistance Payments I-1534.30

1534.31 Income Based on Need I-1534.30

1534.32 Income Tax Refunds and I-1534.30

Credits

1534.33 Indemnity Medical Insurance I-1534.33

Benefits (Income Replacement

Policies)

1534.34 Indian Related Payments I-1534.33

1534.35 Individual and Family Grant I-1534.33

Assistance

1534.36 Inheritance I-1534.36

1534.37 In-Kind Income I-1534.37

1534.38 In-Kind Support and 2 of I-1534.37

Maintenance

1534.39 Insurance Payments I-1534.39

1534.40 Interest I-1534.39

1534.41 Irregular or ** Infrequent I-1534.40

Income

1534.42 Job Training Partnership I-1534.42

Act (JTPA)



1534.43 Lease Arrangements for I-1534.42

Mineral and Surface Rights

1534.44 Life Insurance I-1534.44

1534.45 Loans I-1534.44

1534.46 Lump Sum Payments 2 of I-1534.45

1534.47 Migrant Worker Income I-1534.47

1534.48 Mineral Rights I-1534.47

1534.49 Military Pay and Allowance I-1534.47

1534.50 Mortgages and Promissory I-1534.47

Notes

1534.51 Pensions and Annuities I-1534.52

1534.52 Railroad Retirement Benefits I-1534.52

1534.53 Recoupments I-1534.52

1534.54 Reimbursements I-1534.52


1534.56 Rental Property Income I-1534.56

1534.57 Reparation Payments 2 of I-1534.56

1534.58 Restitution Payments I-1534.58

1534.59 Retirement Benefits I-1534.58

1534.60 Royalties I-1534.58

1534.61 Salaries I-1534.58

1534.62 Scholarships I-1534.58

1534.63 Self-Employment Earnings I-1534.63 Reissued May 1, 1999 38 Replacing April 1, 1992 Table of Contents "**" Text Deleted "ITALICS" Text Revised


1534.64 Senior Community 4 of I-1534.63

Service Employment

Program (SCSEP)

1534.65 Sheltered Workshop 4 of I-1534.63

Earnings

1534.66 Sick Pay 4 of I-1534.63

1534.67 Social Security I-1534.66

Retirement, Survivors and

Disability Insurance Benefits

(RSDI)

1534.68 Spousal Impoverishment I-1534.68

Allocated Income

1534.69 Student Earnings I-1534.68

1534.70 Supplemental Security I-1534.68

Income (SSI)

1534.71 Trust Income and I-1534.70

Tutorship Funds

1534.72 Undivided Estate Income I-1534.72


Benefits (UCB)

1534.74 Vendor Payments I-1534.72 Reissued May 1, 1999 39 Replacing April 1, 1992 Table of Contents "**" Text Deleted "ITALICS" Text Revised


1534.75 Veteran=s Administration I-1534.75

(VA) Benefits

1534.76 Victim=s Compensation I-1534.76

1534.77 Wages, Salaries and I-1534.76

Commissions

1534.78 Worker=s Compensation I-1534.76

1535 Need - SSI-Related - Treatment I-1535

of Income

1536 Deductions I-1535

1537 Spousal Impoverishment Income I-1537

Provisions

1537.1 General Information I-1537

1537.2 Ownership of Income I-1537.2

1537.3 Patient Liability I-1537.2

Determination (Post

Eligibility Determination)

1537.4 Verification I-1537.4

1537.5 Documentation I-1537.4

1540 Need - Income - Programs Not I-1540

Related to AFDC or SSI Reissued May 1, 1999 40 Replacing April 1, 1992 Table of Contents "**" Text Deleted "ITALICS" Text Revised


1541 Qualified Medicare Beneficiary (QMB) I-1541

1541.1 Income Unit I-1541

1541.2 Types of Income I-1541

1541.3 Deductions I-1541

1542 Qualified Disabled and I-1542

Working Individuals (QDWI)


1542.2 Types of Income I-1542

1542.3 Deductions I-1542 1543 Specified Low-Income Medicare I-1543

Beneficiary (SLMB)


1543.2 Type of Income I-1543

1543.3 Deductions I-1543

I-1600 Need - Resources I-1600


1610.1 Resource Standards I-1600

1610.2 Determining Countable Value I-1610.2

1610.3 Conversion of a Resource I-1610.3

1611 Verification I-1610.2


1620 Need - C-Related Resources I-1620 Reissued May 1, 1999 41 Replacing April 1, 1992 Table of Contents "**" Text Deleted "ITALICS" Text Revised



1622 Resource Unit I-1620

1623 Reserved

1624 Types of Resources (C-Related) I-1620


Payments

1624.2 Burial Insurance I-1624

1624.3 Burial Plot I-1624

1624.4 Certificates of Deposit I-1624

1624.5 Crops In Storage I-1624.5

1624.6 Disaster Payments I-1624.5

1624.7 Earned Income Tax Credit I-1624.5

1624.8 Energy Assistance Payments I-1624.5

1624.9 Escrow Accounts I-1624.5

1624.10 Home I-1624.10

1624.11 Housing and Urban I-1624.11

Development (HUD) Benefits

1624.12 Inaccessible Resources I-1624.11

1624.13 Income I-1624.11

1624.14 Income-Producing Property I-1624.11

1624.15 Indian and Native Claims I-1624.11

and Lands

1624.16 Individual Retirement I-1624.16

Accounts (IRA)



1624.17 Jointly Owned Resources I-1624.16

1624.18 Joint Accounts I-1624.18

1624.19 Keogh Plans I-1624.19


1624.21 Livestock I-1624.19

1624.22 Lump Sum Payments I-1624.22

1624.23 Personal Property I-1624.23

1624.24 Real Estate Other Than I-1624.23

Home


1624.26 Retirement Plan I-1624.25

1624.27 Trust Funds I-1624.25

1624.28 Tutorship Funds I-1624.28

1624.29 Vehicles I-1624.28

1624.30 Wartime Relocation of I-1624.30

Civillians Payments

1624.31 Women, Infants, and I-1624.30

Children (WIC) Program

1625 Transferring Resources I-1625

1630 Need - SSI-Related Resources I-1630


1632 Resource Unit I-1630


1634 Types of Resources (SSI-Related) I-1634


Payments

1634.2 Annuities I-1634



1634.3 Bank Accounts I-1634

1634.4 Bonds I-1634.4

1634.5 Burial Contracts I-1634.5

1634.6 Burial Funds I-1634.5

1634.7 Burial Spaces I-1634.7

1634.8 Cash 2 of I-1634.7

1634.9 Certificates of Deposit 2 of I-1634.7

1634.10 Crops in Storage I-1634.10

1634.11 Death Benefits I-1634.10

1634.12 Disaster Assistance I-1634.10

1634.13 Escrow Accounts I-1634.13

1634.14 Estate I-1634.13

1634.15 Home Property I-1634.13

1634.16 Inheritances I-1634.13

1634.17 Jointly Owned Resources I-1634.17


1634.19 Livestock I-1634.19

1634.20 Loans I-

1634.19

1634.21 Lump Sum Payments I-1634.19

1634.22 Mortgages and Promissory I-1634.22

Notes

1634.23 Mutual Fund Shares I-1634.23

1634.24 NOW Accounts I-1634.23

1634.25 Patient Fund Accounts I-1634.23

1634.26 Pension Funds I-1634.23

1634.27 Promissory Notes I-1634.23

1634.28 Property I-1634.28



1634.29 Recreational Vehicles (Boats, I-1634.29

Motors, and Campers)


1634.31 Reparation Payments I-1634.29

1634.32 Restitution Payments I-1634.32

1634.33 Retirement Funds I-1634.32

1634.34 Safety Deposit Boxes I-1634.34

1634.35 Savings Bonds I-1634.34

1634.36 Savings Certificates I-1634.34

1634.37 Stocks I-1634.37

1634.38 Time Deposits 2 of I-1634.37

1634.39 Trusts I-1634.39

1634.40 Vehicles I-1634.40

1634.41 Victims= Compensation 2 of I-1634.40

Payments

1660 Spousal Impoverishment Resource I-1660

Provisions (LTC/HCBS)


1662 Definitions I-1662

1663 Spousal Resources Assessment I-1663

1664 Resource Assessment Procedures 2 of I-1663

1665 Transfer to Community Spouse I-1665

1666 Transfer of Resources by I-1666

Community Spouse

1667 Revisions to Allocated Resources I-1667



1668 Undue Hardship I-1667

1669 Notification I-1669

1670 Transfer of Resources for Less I-1670

Than Fair Market Value


1672 Transfers Prior to July 1, 1988 I-1672

1673 Transfer On or After July 1, 1988 I-1673

1674 Transfers On or After August 11, 1993 I-1674

1675 Uncompensated Value I-1675

1676 Effect of Uncompensated Value I-1676

on Eligibility

1677 Receipt of Additional Compensation 5 of I-1676

1678 Return of Transferred Resources I-1678

1679 Rebuttal of Presumed Value I-1679

1680 Need - Resources - Programs I-1680

Not Related to AFDC or SSI

1681 Qualified Medicare I-1681

Beneficiary (QMB)

1681.1 Requirement I-1681

1681.2 Resource Unit I-1681


1681.4 Types of Resources I-1681

1682 Qualified Disabled and Working I-1682

Individuals (QDWI)







1683 Specified Low-Income Medicare I-1683

Beneficiary (SLMB)





I-1700 Medicaid Qualifying Trusts I-1710

1710 Medicaid Qualifying Trusts I-1710

1720 Treatment of Trusts Created on Or I-1720

After August 11, 1993

I-1800 Relationship I-1800



1820.1 Temporary Certification I-1820

Pending Verification of

Relationship

1820.2 Sources of Verification I-1820

1820.3 Selection of a Collateral I-1820.2

Source

1820.4 Confidentiality I-1820.2

1820.5 Evaluation of Collateral I-1820.4

Information

1820.6 Responsibility for Obtaining I-1820.4

Verification

1820.7 Worker Responsibility I-1820.7

1820.8 Sources for Verification I-1820.7

1830 Documentation I-1820.8



I-1900 Residence I-1900


1910.1 Individuals Under Age 21 I-1910

1910.2 Individuals Age 21 and Over I-1910.1

1911 Change in Residency I-1911

1912 Temporary Visits Out of State I-1912

1913 Interstate Residency Agreements I-1912

1914 Interstate Compact on Adoption I-1914

and Medical Assistance (ICAMA)

1915 Inquiries Concerning Residence I-1915



I-2000 Support Enforcement Services I-2000


2010.1 Pregnant Woman Only I-2000

2010.2 Pregnant Woman With I-2010.2

Minor Child

2011 Notification I-2011

2012 Automatic Assignment of Medical I-2011

Support

2013 Cooperation I-2013

2013.1 Requirement to Cooperate I-2013

With SES (Other Than

Pregnant Woman)

2013.2 Good Cause Claim I-2013.2

2014 Referrals to SES I-2014



2015 Non-Cooperation I-2015

2015.1 Penalties for 2 of I-2015

Non-Cooperation With SES



I-2100 Supplemental Security Income (SSI) I-2100

Eligibility


2110 SSI Eligibility Requirement I-2110


2110.2 Documentation I-2110

2120 Loss of SSI or MSS Requirement I-2120


2120.2 Documentation I-2120

2130 Concurrent Eligibility for I-2130

and Receipt of SSI or MSS and

RSDI Requirement

2130.1 Verification I-2130.1

2130.2 Documentation I-2130.1

Reissued May 1, 1999 49 Replacing June 1, 1992 Table of Contents "**" Text Deleted "ITALICS" Text Revised


J-0000 Issuing Medical Eligibility Cards (MECS) and J-0000

Optional State Supplement (OSS) Checks - Outline

J-100 General Information J-100

J-200 Medical Eligibility Cards (MECs) J-200

210 State Office Issuance J-200

211 Fiscal Intermediary Issuance J-211

212 Local Office Issuance J-212

212.1 Initial Issuance J-212.1

212.2 Prior Period Eligibility J-212.1

212.3 Lock-In J-212.1

212.4 Replacement J-212.4

212.5 Procedures For Issuing J-212.5

MECs

213 When To Retrieve A MEC J-213

214-229 Reserved

230 Messages on MECs J-230

240-249 Reserved

250 Medical Insurance Codes J-250

260 Third Party Payee (C-Related Only) J-260

260.1 Standards of Selection J-260

260.2 Locating a Third Party Payee J-260.2

260.3 Third Party Payee J-260.2

Responsibilities

260.4 Qualified Relative J-260.2

Responsibilities

260.5 Confidentiality J-260.2

J-300 Optional State Supplement (OSS) Checks J-300


Medicaid Eligibility Manual Table of Contents K-0000 Redeterminations - Outline K-0000

K-100 Requirement K-100

K-200 Redetermination Listing K-200

K-300 Processing Redeterminations K-200

K-400 Incomplete Redeterminations K-300

K-500 Incapacity or Disability K-300

Decision

L-0000 Changes - Outline L-0000

L-100 Requirement L-100

L-200 Changes That Must Be Reported L-200

L-300-400 Reserved

L-500 Action on Changes L-500

L-600 Adequate Notice L-600

L-700 Advance Notice L-700

L-800 Mass Changes L-700

L-900 Appeal Requests L-900

M-0000 Transfers - Outline M-0000

M-100 General Information M-100

M-200 Active Cases M-200

M-300 Pending Applications M-300



N-0000 Special Processing - Outline N-0000

N-100 EPSDT/KIDMED N-100

110 General Information N-100

120 Coverage N-100

130 Information Requirements N-130

130.1 Initial Information N-130

140 KIDMED Responsibilities N-140

150 Qualified Provider Responsibilities N-140

160 OCS/OYD Responsibilities N-140

N-200 Lock-In N-200

210 Definition N-200

220 Exclusions N-220

230 Who May Be Placed in Lock-In N-220

240 DHH Responsibilities in Placing N-240

the Recipient in Lock-In

241 OFS/BHSF Responsibilities in N-241

Placing the Recipient in Lock-In

N-300 Mandatory State Supplement (MSS) N-300


320 Minimum Income Level (MIL) N-320

330 Reserved

340 Special Needs N-340

340.1 Essential Person N-340.1

340.2 Housekeeping Services N-340.2

340.3 Room and Board/Change N-340.2

In Living Arrangement



340.4 Shelter N-340.2

340.5 Special Care Needs N-340.5

340.6 Transportation and N-340.5

Dependent Care

350 Computing the Special Needs N-350

Budget

360 Redetermination Period 2 of N-350

N-400 Out-of-State Medical Care N-400


420 Services N-400

430 Head Injuries/Traumatic Brain N-430

Injuries/Rehabilitative Care

N-500 Reserved

N-600 Supplemental Security Income (SSI) - Medicaid N-600

610 Introduction N-600

620 Certification Process N-600

630 OCS Children N-620

O-0000 Prior Authorization - Outline O-0000

O-100 Introduction O-100

O-200 Prior Authorization for Medical Equipment, O-200

Appliances, and Supplies

201 General Information O-200

201.1 Requirements for O-200

Approval

201.2 Medicare Part B Recipients O-201.2

201.3 Time Limits O-201.3

201.4 Purchase vs. Rental O-201.3



201.5 Freedom of Choice O-201.3

201.6 Coverage for EPSDT Eligibles O-201.6

201.7 Nursing Home Responsibilities O-201.6

For DME and Medical Supplies

202 Requests O-202

202.1 Emergency Requests O-202.1

203 Delivery Arrangements O-203

204 Items Requiring PAU Authorization O-204

204.1 Abdominal Binder and O-204

Supports

204.2 Adaptive ** Hygiene O-204

Equipment

204.3 Aerosol Compressor O-204

Nebulizers

204.4 Air Filters O-204.4

204.5 Alternating Pressure Beds O-204.4

204.6 Apnea Monitor O-204.6

204.7 Artificial Eyes 2 of O-204.6

204.8 Artificial Larynxes 2 of O-204.6

204.9 Augmentative Communication O-204.9

Devices

204.10 Batteries 2 of O-204.9

204.11 Bilirubin Lamps O-204.11



204.12 Breast or Mammary ProsthesesO-204.11

204.13 Burn Garments and O-204.13

Stockings

204.14 Canes and Crutches O-204.13

204.15 Catheters O-204.13

204.16 Commode Chairs O-204.13

204.17 Continuous Positive O-204.17

Airway Pressure (CPAP)

Devices

204.18 Dialysis Equipment and O-204.18

Supplies

204.19 Egg-Crate Type Mattresses O-204.18

204.20 Glucose Monitors O-204.20

204.21 Hearing Aids (**Medicaid O-204.20

Eligibles Under Age 21 Only)

204.22 Hearing Aid Batteries and O-204.21

Repairs

204.23 Hospital Beds, Mattresses, O-204.21

Rails (Standard Types)

204.24 Hospital Beds (Electric) O-204.23

204.25 Hyperalimentation Therapy O-204.23

Aids (Parental and Enteral)

204.26 Irrigation Equipment 4 of O-204.25 Reissued May 1, 1999 55 Replacing June 1, 1992 Table of Contents "**" Text Deleted "ITALICS" Text Revised


204.27 IV Therapy Pumps and 4 of O-204.25

Administrator Supplies

204.28 Lifts ** O-204.28

204.29 Mechanical Percussors O-204.28

204.30 Orthopedic Shoes and O-204.28

Corrections

204.31 Orthotic Devices O-204.30

204.32 Ostomy Equipment O-204.32

204.33 Oxygen Concentrators O-204.32

204.34 Prosthetic Devices 2 of O-204.33

204.35 Repairs O-204.35

204.36 Seat Cushions for Wheelchairs O-204.35

204.37 Sheepskins O-204.35

204.38 Side Rails for Beds Othe r O-204.35

Than Hospital Beds

204.39 Suction Machines O-204.35

204.40 Support Hose O-204.39

204.41 Surgical Dressings or BandagesO-204.39

(Gauze, Tape, Sponges, Cement,

And Disposable Gloves)

204.42 Surgical Mastectomy Bras O-204.39 Reissued May 1, 1999 56 Replacing June 1, 1992 Table of Contents "**" Text Deleted "ITALICS" Text Revised


204.43 Traction Equipment O-204.43

204.44 Trapeze Bars O-204.43

204.45 Urinals (Hospital Type) and O-204.43

Bed Pans

204.46 Ventilators (Mechanical O-204.43

Breathing Machines) and

Required Accessories

204.47 Walkers O-204.47

204.48 Wheelchairs and Strollers O-204.47

205 New Eyes For The Needy, Inc. O-205

O-300 Medical Transportation O-300

301 General Information O-300

302 Who Is Eligible O-300

302.1 Children in State Custody O-302.1

302.2 Applicants O-302.1

303 Applicant's/Recipient's Trade O-303

Area

304 Ambulance Transportation O-304

305 Non-Ambulance, Non-Emergency O-304

Medical Transportation (NEMT)



305.1 Services For Which NEMT O-305.1

Transportation Can Be

Provided

305.2 NEMT Transportation O-305.2

Providers

305.3 Transportation Provider's O-305.3

Service Area

306 NEMT Requests O-306

307 Verification of Eligibility for O-306

Transportation Services

308 Exploring Transportation O-308

Alternatives

308.1 Recipient and Community O-308

Resources

308.2 Title 20 Funds O-308.2

309 Selecting a Provider O-309

309.1 City/Public Transportation O-309

309.2 Contract Providers O-309.2

309.3 Freedom of Choice O-309.2

310 Use of Attendants O-310

311 Choice of Vehicle O-311

312 Verification Required O-311

313 Authorizing NEMT O-313

313.1 Rescheduling O-313

314 PAU Authorization O-314

315 Documentation O-315


Medicaid Eligibility Manual Table of Contents 316 Transportation Provider O-316

Responsibilities

317 Responsibilities After O-317

Transportation Services Are Provided

318 Claim Forms O-318

318.1 Review of Claim Forms O-318

P-0000 Third Party Liability (TPL) - Outline P-0000

P-100 General Information P-100

P-200 Indicators of Potential Third Party P-200

Resources

P-300 Assignment/Cooperation 2 of P-200

P-400 Local Office/BHSF Responsibilities P-400

410 Health Insurance Resource Form P-400

411 Railroad Retirement Medicare P-411

Entitlement

420 TPL Carrier Update Form CF-1 P-411

430 Accident/Injury Reports P-430

440 Request for Accident/Injury P-440

Report Form Disposition

P-500 Buy-In Program P-500

510 General Purpose P-500

520 Part A Buy-In P-500

530 Part B Buy-In P-500


Medicaid Eligibility Manual Table of Contents Q-0000 Inquiries and Complaints - Outline Q-0000

Q-100 Agency Responsibility Q-100

110 Billing 2 of Q-100

120 Third Party Resource File Q-120

Other Than Medicare

130 Long Term Care Q-130

Q-200 Referrals Q-200

210 Referrals to BHSF Q-200

220 Referrals to Fiscal Intermediary Q-220

R-0000 Authorized Representation R-0000

R-100 Authorized Representation R-100

S-0000 Verification and Documentation - Outline S-0000

S-100 Verification S-100

110 Questionable Information S-110

120 Documentary Evidence S-120

130 Collaterals S-120

S-200 Documentation S-200

T-0000 Fair Hearings - Outline T-0000

T-100 General Information T-100

U-0000 Fraud and Recovery - Outline

U-100 Fraud U-100

110 Suspected Recipient Fraud U-100

120 Suspected Provider Fraud U-100



U-200 Recovery U-200

210 Agency Responsibility U-210

220 Recovery Report U-220

230 Amount of Ineligible Payment U-230

and Amount of Recovery

V-0000 Reserved

W-0000 Reserved

X-0000 Reserved

Y-0000 Reserved

Z-0000 Charts - Outline Z-0000

Z-100 Reserved

Z-200 Federal Poverty Income Guidelines Z-200

Z-300 Medically Needy Eligibility Z-300

Standards (MNIES) Urban Areas

Z-300 Medically Needy Eligibility 2 of Z-300

Standards (MNIES) Rural Areas

Z-400 Federal Benefit Rate (FBR) Z-400

Z-500 QMB Income Limits Z-400

Z-600 QDWI Income Limits Z-600

Z-700 LTC/HCBS/Psychiatric Hospital - CAP Z-700

Rate, Resource Limits, and Personal

Care Needs Allowance

Z-800 Spousal Impoverishment Maintenance Needs Z-800

and Resource Standards

Z-900 Resource Limits by Program Z-900



Z-1000 Maximum Resource Limits as of 12-73 for Z-1000

Grandfathered/Converted Recipients

Z-1100 Maximum Grants for MSS Categories A, B, Z-1100

and D Prior to Conversion to SSI

Z-1200 Life Expectancy Tables - Males Z-1200

Z-1200 Life Expectancy Tables - Females 2 of Z-1200

Z-1300 Usufruct and Remainder Interest Tables Z-1300

Z-1400 Social Security Cost of Living Z-1400

Adjustment (COLAS) Extended Medicaid Only

Z-1500 Deeming Allowances Z-1500

Z-1600 SLMB Income Limits Z-1600

Z-1700 AFDC Need Standard and Flat Grants - Z-1700

Urban Areas

Z-1700 AFDC Need Standard and Flat Grants - 2 of Z-1700

Rural Areas

Z-1800 SSI Disability Denial Codes Z-1800

Z-1900 CHAMP Income Limits Z-1900

Z-2000 Qualified Individuals Z-2000

Index


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Table of Contents - Louisiana Department of Health and Hospitals

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