SUBJECT: Medicaid Suspension for Incarcerated Recipients; Coverage for Inpatient Hospitalization
DISTRIBUTION: County Directors of Social Services
Medicaid Eligibility Staff
Administrative Letter 09-08 provided policy and instructions to suspend rather than terminate Medicaid benefits for authorized recipients who are incarcerated or who enter an Institution for Mental Diseases (IMD). Medicaid is suspended when a recipient becomes incarcerated or when he is age 21 through 64 and enters an IMD, provided he remains otherwise eligible for Medicaid.
The only services that are covered while a recipient’s Medicaid is in suspension for incarceration are medical services received during an inpatient hospital stay. In the 2010 Appropriations Act, the state legislature mandated that the Department of Corrections (DOC) Division of Prisons (DOP) work with the Division of Medical Assistance (DMA) to develop protocols for individuals incarcerated in North Carolina prisons who may be eligible for Medicaid in suspension to access Medicaid while in custody or under extended limits of confinement (i.e. in long term care facilities). This legislation requires that eligibility be determined for incarcerated prisoners who are not already in suspended status. Coverage remains limited to inpatient hospitalizations, but eligibility includes incarcerated individuals under 21. Previously, state funds were used to pay for these inpatient hospitalizations. The legislation applies only to prisoners in North Carolina state prisons. The policy in DMA Administrative Letter 09-08 remains applicable to individuals who are incarcerated in other penal institutions and individuals in an IMD.
A recent data match of the prisoner population with current Medicaid recipients showed that counties were unaware of the incarcerated status of the majority of those recipients. DOP will share inmate information with DMA in order to facilitate changing the eligibility of those recipients who have been incarcerated to suspended status. This helps prevent fraud and payment of improper claims.
DOP is providing an initial file of the existing 40,000+ prison population to be used to match data against current recipient eligibility (including individuals who are caseheads only) in EIS. The match includes all aid program/categories in EIS (including Work First, SA, etc.) The individuals identified from this match are included in a report in NCXPTR for counties to use to suspend Medicaid benefits of all eligible prisoners and to terminate individuals who are not eligible for suspension. If the report is not available by September 13, a listserv message will be sent to notify you when it is available.
There may be individuals who are in a North Carolina prison who are not included in the report because there was not an exact match of demographic data between the DOP file and EIS. When you learn of an individual that is incarcerated, but is not on the report, continue to follow policy in DMA Administrative letter 09-08 to suspend or terminate benefits.
Future daily file matches between DOP and EIS are being developed (See II.D.)
If the individual is receiving as a caretaker, evaluate for eligibility in all other program categories including MPW (incarceration is not considered a temporary absence for purposes of caretaker eligibility).
An incarcerated individual cannot remain as a casehead. If the incarcerated individual is a casehead, review the case file for other family members or third party contact information. Contact the family member or third party and find out with whom the children are living. Obtain the information necessary to replace the casehead. Substitute the name of the new casehead for the incarcerated casehead. Change the address and phone number if necessary.
DOP will continue to send applications for prisoners who are scheduled for release to the county where the prisoner is expected to live. Follow existing policy for receiving mail-in applications (MA-2302/3207) and for processing applications. Contact the applicant at the address shown on the application for all needed information.
Key “M” in HOW APP RECEIVED field on the 8124 screen.
A new source code has been assigned for applications received from DOP for inmates who will remain incarcerated. Key “P” in the HOW APP RECEIVED field on the 8124 screen.
At this time EIS is not able to accommodate incarcerated individuals in long term care, including those hospitalized over 30 days. This policy will be issued and effective at a later date. Until new policy is issued, place these individuals in suspended status as you are doing for other prisoners.
Automated notices will be mailed to the Division of Prisons based on the address you enter in EIS. Manual notices should be sent to the Medicaid Coordinator at the DOP (see III.C.5. for address).
Currently Medicaid cards are not issued for suspended Medicaid recipients. We are in the process of changing this in order for Medicaid cards to be issued and mailed to the Division of Prisons. You will be notified when this change occurs.
DOP will notify the county of any changes in an inmate’s situation. If the inmate is to be discharged, DOP will provide the recipient’s new address. If the individual is relocating to another county, follow procedures in MA-2221/3340, County Residence, to transfer the case once the recipient has been released and is living at the new address.
DMA is working on policy and EIS changes for processing redeterminations of eligibility for prisoners in suspension status. Until such policy is in place, continue to follow redetermination instructions in DMA Administrative Letter 09-08.
This policy is effective September 13, 2010. Apply this policy to all applications received from DOP on or after September 13, 2010. Apply this policy to all dates of service on or after July 1, 2010.
If you have any questions regarding this material, please contact your Medicaid Program Representative.
Craigan L. Gray, MD, MBA, JD,
(This material was researched and written by Mary Spivey, EIS Consultant and William Appel, Policy Consultant, Medicaid Eligibility Unit.)
For questions or clarification on any of the policy contained in these manuals, please contact your local county office.