Disability and Medically Frail 510-03-35-100

(New 7/1/2014 ML #3404)

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(N.D.A.C. Section 75-02-02.1-14)

 

Under final rules for the Affordable Care Act published on July 15, 2013, individuals determined eligible under the Adult Expansion Group MUST be given the option to be covered under a broader coverage plan.

Note: All determinations for this coverage are done at the state office.

Once eligibility under the Adult Expansion Group is determined, the approval notice includes information informing the recipient to provide verification of their disability and assets if they would like to receive broader coverage under the ‘medically frail’ provisions. It is Medicaid’s obligation to screen for the disability.

 

Recipients, who request to be considered for coverage as ‘medically frail’, MUST complete a self-assessment, using SFN 1598, and return the completed form to:

DHS Medical Services

600 E Boulevard Ave, Dept. 325

Bismarck ND 58505-0250

EMAIL: medicallyfrail@nd.gov

 

EXCEPTION #1: If the individual is a Medicare beneficiary and not eligible under the Parents, Caretaker Relative’s and their Spouses Category, that individual must be tested under Non-ACA Medicaid.

 

EXCEPTION#2: If the individual is determined disabled by the Social Security Administration and is eligible under Non-ACA Medicaid or ACA Medicaid, other than the Adult Expansion Group, the ‘medically frail’ provisions do not need to be pursued for these individuals.

 

EXCEPTION #3: ‘Medically Frail’ provisions do not apply to individuals over age 65.

 

Individuals requesting coverage as Medically Frail, who complete the self-assessment:

• If the self-assessment meets a threshold score set by the department, the individual shall schedule an appointment with a primary care provider to review and validate the information on the self-assessment. After the individual attends a face-to-face appointment with the primary care provider, the individual shall ensure that the primary care provider provides documentation to the department that validates the diagnosis or medical condition and that includes a medication list.

Upon review of the information provided by the primary care provider, the department shall determine whether the individual meets ‘medically frail’ eligibility requirements.

If the individual eligible under the Adult Expansion Group:

• Is approved for eligibility as ‘medically frail’, the individual may choose coverage through a Managed Care Organization (currently, the coverage under the Sanford Health Plan) or through the Medicaid State Plan fee-for-service.

Individuals determined ‘medically frail’ and who are requesting assistance for nursing care services are subject to the Disqualifying Transfer Provisions described in Service Chapter 510-05, Medicaid Eligibility Factors for Non-ACA Medicaid , Section 510-05-80, Disqualifying Transfers.

• Is denied for eligibility as ‘medically frail’, the individual will remain eligible under the Adult Expansion Group.

Coverage of an individual approved as ‘medically frail’ will begin the first of the month following the month in which the determination is made.

 

If the individual who requested a ‘medically frail’ determination also applied for SSA Disability:

1. If the individual is found not disabled by State Review Team and/or SSA, we will continue coverage under the Adult Expansion group.

2. If the individual is determined disabled by the Social Security Administration or the State Review Team and is not eligible for Non-ACA Medicaid or ACA Medicaid other than the Adult Expansion Group, the individual will continue eligible under the Adult Expansion Group.

3. If the individual does not cooperate, does not provide verification of disability or assets, or refuses to do so, but is otherwise eligible for the Adult Expansion Group, coverage will continue under the Adult Expansion Group.

4. Refer to ‘Processing for Individual's Claiming to be Disabled (Medically Frail)’ section of the ACA Medicaid Processing Guide.