HF3439

Purpose

• Expand and speed up how medical assistance (MA) eligibility is determined for certain high‑risk groups.
• Create a streamlined process within the State Medical Review Team to issue disability determinations faster.
• Update rules related to how income and assets are counted for MA eligibility, and set standards for contract requirements with managed care plans.
• Include a review of the death master file as part of the process to improve accuracy and prevent improper determinations.

Main Provisions

• Expedited disability determinations (within the State Medical Review Team)

  • The commissioner must establish an expedited disability determination process for applicants in specific high‑risk categories.
  • Eligible groups include:
  • People in facilities who cannot be discharged without home and community‑based services or long‑term care in place.
  • People with lifethreatening medical conditions needing urgent treatment or prescription meds.
  • People diagnosed with a condition on the Social Security Administration’s Compassionate Allowance List.
  • Children under two who screen positive for a rare disease recognized by national medical registries or standards.
  • People enrolled under a particular MA eligibility category who are at risk of losing MA eligibility.
  • Hospitals requesting expedited determinations must first file an MA application and help provide required documentation.

• Administration and coordination

  • The State Medical Review Team will designate staff to coordinate expedited requests, communicate with counties and tribal agencies, and ensure timely electronic transmission of documentation, including electronic signatures.
  • If electronic health records aren’t available, providers must work with the state team to obtain necessary medical records.
  • The commissioner must maintain contracts for electronic signature and document transmission services to support expedited determinations.

• Death master file review

  • The bill contemplates review related to death master file information as part of the eligibility/verification process (to improve accuracy and prevent improper determinations).

Changes to Existing Law (Income, Assets, and MAGI)

• General income and asset rules for MA eligibility

  • For people whose MA eligibility depends on blindness, disability, or age 65+, the standard SSI methodologies are used unless the bill specifies otherwise.
  • State tax credits, rebates, and refunds are not counted as income.
  • State tax credits, rebates, and refunds are not counted as assets for 12 months after receipt.
  • Increases in SSA Title II benefits are not counted as income until July 1 of each year (subject to federal approval).

• MAGI-based eligibility for certain groups

  • The bill adopts MAGI (modified adjusted gross income) methods for eligibility categories that include:
  • Children under 19 and their parents/relative caretakers
  • Young adults ages 19–20
  • Pregnant women
  • Infants
  • Adults without children
  • For these groups, eligibility uses MAGI, not traditional asset/income standards, and does not count as an “asset or income standard” for determining the eligibility method.
  • MAGI-based eligibility uses a specific adjustment: subtract 5% of the federal poverty guidelines from MAGI, and determine eligibility monthly using current income and household size for a 12‑month period.
  • If income is expected to vary month to month, eligibility is based on the income predicted for the 12‑month period.

• 12‑month eligibility and income considerations

  • When income is used to determine MA eligibility for MAGI groups, the 12‑month period is used to determine eligibility, with adjustments for changes in income over time as described above.

• Effective dates for certain groups

  • Some provisions become effective upon federal approval for children eligible under the listed section and for certain home and community‑based waiver services.

Implementation and Administrative Details

• Provider and hospital responsibilities

  • Hospitals must complete an MA application before submitting an expedited request and assist patients in providing documentation.
  • The state team coordinates with counties and tribal agencies and ensures timely electronic communication and record sharing.

• Technology and records

  • The bill requires electronic signature and document transmission capabilities to support expedited determinations.
  • If electronic health records are unavailable, providers must coordinate to obtain the needed medical records.

Potential Impact

• Access and speed
  • Faster disability determinations for high‑risk groups could reduce delays in receiving medical care and supports.
• Administrative efficiency
  • Standardized processes for documentation, electronic communication, and signatures may reduce administrative barriers and improve timeliness.
• Eligibility changes
  • Shifting to MAGI for several groups and altering how income/assets are counted could change who qualifies for MA for those groups.

Implementation Notes

• Federal approvals and coordination with state systems (e.g., electronic signatures, EHRs) will influence timing.
• The focus is on high‑risk cases and ensuring timely access to needed services and supports.

Relevant Terms - expedited disability determination - state medical review team - high‑risk categories - home and community‑based services - long‑term care supports - lifethreatening medical conditions - Compassionate Allowance List - rare disease - electronic signature - electronic transmission - electronic health records (EHR) - death master file - MA (medical assistance) - MAGI (modified adjusted gross income) - income and assets methodology - SSI program methodologies - state tax credits, rebates, and refunds - 12‑month eligibility period - federal poverty guidelines - current monthly income and household size