Federal regulations require that transportation services be provided to Medicaid recipients:

• when necessary for medical care (diagnosis or treatment);
• when transportation is otherwise not available;
• in the least expensive means suitable to the recipient's medical needs; and
• to transport recipients to qualified providers who are generally available and used by other residents of the community.

Free transportation will be used when available and when suitable to the needs of the recipient.

Qualified Medicare Beneficiaries, Specified Low Income Medicare Beneficiaries and Qualified Disabled Working Individuals are not eligible for transportation services.

County offices will not authorize transportation for ICF/MR or nursing facility residents or residents of the Hot Springs Rehabilitation Center, as these facilities are responsible for transporting their clients.

If a nursing facility administrator believes that unusual circumstances place transportation services outside the scope of his responsibility and requests assistance from the County Office, the County Office travel supervisor should call the Office of Long Term Care (682-8489) for a decision.

Transportation may be provided when a recipient needs to travel to and from a medical facility that provides medical services covered by Medicaid. A medical facility is defined as a place where medical examinations and treatment are received. Medical facilities include hospitals, doctors' offices, dentists' offices, clinics, independent laboratories, X-ray facilities, Developmental Day Treatment Clinics, pharmacies and drug stores (for purchase of prescription drugs and prescription medical supplies), and the Health Department.

Medicaid transportation will not be provided for a non-Medicaid-covered service (e.g., transportation would not be authorized to a psychologist for an individual over age 21, since this is not a covered service). "Your Guide to Medicaid Services in Arkansas" lists the services covered by Medicaid.

Some Medicaid recipients are required to choose a primary care physician (PCP) to take care of their medical needs, and can generally obtain other medical services only upon a referral from their PCP. If a recipient is required to have a PCP, transportation will be authorized by the County Office only to the PCP or to a physician or medical services referred to by the PCP when referral is required. Counties may accept a client's statement that a medical appointment is with the recipient's PCP or a PCP referral unless the recipient has a history of abuse of transportation privileges. If the statement is questionable or if there is a history of abuse, verification of the PCP or the PCP referral should be obtained.

Some individuals are excluded from PCP selection. They are nursing home and ICF/MR, Medicare, Children's Medical Services, Medically Needy Spend Down recipients, and those who have retroactive eligibility only or who are temporarily absent from the state (e.g., a foster child placed out of Arkansas).

There are some Medicaid services a recipient can receive without a referral from a PCP (e.g., dental services for children under age 21). If a service does not require a PCP referral, transportation may be paid to a provider chosen by the recipient. For a list of services that does not need a PCP refer to the form DCO-2613.

When a recipient is not required to have a PCP or when a PCP referral is not required to obtain a Medicaid covered service, a recipient may go to any provider he chooses but Medicaid funds will not be used to pay for transportation if the distance is unreasonable.

Generally, mileage will be paid to and from the nearest qualified provider, even if the recipient chooses to see a provider farther away. However, mileage may be paid to a provider who is farther away than the nearest qualified provider if it is a general practice of the residents of a community to see physicians or obtain other medical services within a larger service area. For example, even though there is a physician in Altheimer, most residents of this Jefferson County community travel to Pine Bluff for medical care.

The above guidelines will prevail for all non-PCP recipients and recipients seeking services for which a PCP referral is not required. Exception: Transportation may be provided to a specific provider for both PCP and non-PCP recipients when court ordered to that provider (e.g., when a child is court ordered to a psychiatric facility).

Transportation for non-PCP recipients may also be provided for a recipient if a referral has been made by a physician or other health care specialist (e.g., an RN at the Health Department) to a provider who is not the nearest qualified provider.

Recipients may be provided transportation to both Medicaid and non-Medicaid enrolled providers.

Medicaid transportation is provided and paid for as follows:

1. Individuals using their own vehicles as Private Transportation providers;

2. Nonprofit organizations such as the Area Agency on Aging or Developmental Day Treatment Clinics using vans or other vehicles;

3. Public transportation (taxicabs); and

4. Ambulance transportation.

All of the above enroll as Medicaid transportation providers, and bill Medicaid directly for their services. County offices do not authorize transportation for these providers.

County offices may authorize transportation and make payment as indicated for the following:

1. Recipients, or to their parents, guardians or other payees when the recipient is a minor or incapacitated (county bank funds at $.09 a mile);

2. Individuals who enroll as volunteers through the county office (TR-1 at current agency employee rate);

3. Foster parents (TR-1; or bank funds at current agency employee rate when transporting foster children in their care); and

4. State employees (TR-1).

County bank funds may also be used to purchase tokens for intracity bus transportation, where available, and for intercity bus transportation.

Medicaid transportation costs can be reimbursed to providers for loaded miles only, regardless of the type of provider or vehicle used. Loaded miles means miles driven while recipients are in the vehicles, i.e., from the point of pickup of the Medicaid recipient to the medical provider and the return home for the recipient. Mileage is not paid from the provider's home, office, or other location to pick up a recipient, nor for the provider to travel to other destinations while the recipient is at the provider's office/facility or after delivery of the Medicaid passenger to his home. Reimbursement begins only when the recipient is loaded into the vehicle, and reimbursement ceases when the recipient leaves the vehicle.

Exception: Volunteers may be reimbursed from their homes to recipients' homes to medical providers, and for the return trip back to the recipients' and volunteers' homes. However, no reimbursement will be made for miles driven during an interim between recipient delivery to and pickup from providers which are not directly connected with recipients' medical travel.: Volunteers may be reimbursed from their homes to recipients' homes to medical providers, and for the return trip back to the recipients' and volunteers' homes. However, no reimbursement will be made for miles driven during an interim between recipient delivery to and pickup from providers which are not directly connected with recipients' medical travel.

If more than one Medicaid recipient is transported at the same time to the same location, the provider may bill for only one recipient. If more than one Medicaid recipient is transported at the same time to different locations, the provider may bill only for the recipient traveling the farthest distance.

Payment to a recipient who comes to the county office for bank funds should be only for the miles from the recipient's home to the medical provider and return home; no extra miles should be paid for travel to the county office.

Medicaid transportation funds are to be used for Medicaid transportation only. This applies to bank funds as well as reimbursement by TR-1.

The funds will not be used for meals, lodging or incidental expenses for a recipient; a recipient's parents, other family members or friends; foster parents; guardians; volunteers; or state employees.

A Medicaid recipient's meals and lodging may be paid for only when domiciliary care is required (Re.[MS 1200.7]).

Meals and lodging are paid for recipients only when domiciliary care is needed. Domiciliary care is not available for recipients if they live within a 50-mile radius of the medical facility where treatment will be obtained unless medical necessity for domiciliary care is established. Domiciliary care is not a commonly used Medicaid service, and county offices do not authorize for this service.

Domiciliary care is provided to a Medicaid recipient who must be fed and housed during a period of receiving medical treatment in a facility which does not provide room and board. For example, a Texarkana resident must undergo a series of radiation treatments at CARTI in Little Rock. The recipient may stay at St. Vincent's or Baptist Medical Center's guest house, either of which will bill Medicaid for meals, lodging and transportation to and from CARTI for daily treatments.

A county office would authorize only round trip transportation for the recipient between Texarkana and Little Rock in the above example.

A therapeutic visit is defined as a meeting of a child with his parents, guardian or foster parents as a part of a treatment plan to help reunite a family whose members have been separated due to the necessity of inpatient psychiatric care for the child.

A county may authorize three therapeutic visits in a calendar year for a family whose child is in an out-of-state facility when a psychologist or psychiatrist has recommended in writing that the visits are medically necessary as a part of the recipient's therapeutic treatment plan (Re. [MS 1200.11] for out-of-state travel).

Transportation may be authorized for the child to visit the parents, etc. or for the non-Medicaid eligible parents, etc. to visit the child, but only three visits per year are allowed when the facility is out-of-state.

If the facility is in Arkansas, unlimited visits may be authorized according to verified medical recommendation.

Only one (1) round transportation trip will be authorized for parents who take their child home from a facility (e.g., weekend visit) and later return the child back to the facility. Medicaid will only pay for the trip to transport the child home and the trip to return the child back to the facility. The parent's trip to return home and the trip to pick up the child will not be covered.

When an emergency occurs over a weekend, at night or on a holiday when the county office is closed, the recipient may be reimbursed for the travel required to obtain medical treatment for the emergency. If the recipient has not requested reimbursement for travel within seven calendar days after the emergency, no reimbursement will be made.

When it is verified that a recipient must make numerous trips to a provider for treatment over a period of time (e.g., for dialysis or radiation therapy), trips may be authorized in advance for the treatments but for no more than two weeks travel per authorization. Before authorizing for additional time, the necessity for the medical visits should be reverified.

Out-of-state transportation can be authorized for recipients to secure necessary medical services.

Medicaid will not pay for transportation services to an out-of-state medical facility to obtain services not covered by Medicaid, nor will it pay for transportation to obtain medical services which are generally available in Arkansas.

The County office will authorize out-of-state travel only if the following conditions are met:

1. The transportation does not involve air travel;

2. The services can be secured more easily and economically out-of-state (i.e., some out-of-state providers may be closer than in-state providers)

3. Travel is to the recipient's PCP or for medical referrals by the PCP in a border city or surrounding areas. The border cities are Poplar Bluff, MO; Memphis, TN; Texarkana, TX; Clarksdale and Greenville, MS; Monroe and Shreveport, LA; and Poteau and Sallisaw, OK.

The Utilization Review Section, Division of Medical Services, will authorize all other out-of-state transportation, including air travel, travel to obtain services which are not available in-state, etc. Requests for travel should be made to the Division of Medical Services, Utilization Review, P.O. Box 1437, Slot 1102, Little Rock, AR, 72203-1437.

All requests which require authorization by Utilization Review should be submitted at least 2 weeks in advance of the scheduled departure date.

In cases of extreme emergency or when further information is needed concerning a request, Utilization Review may be contacted at 682-8329.

Transportation may be authorized with bank funds to former Medicaid recipients who are participating in a utilization review. The County Office will indicate the individual's closed case number, category, and purpose of transportation on the check. The purpose will be for Utilization Review.

An application is not required for Medicaid transportation.

A record should be kept of each recipient's transportation transactions, including SSI recipients. These records must be kept on file and made available to auditors when requested. The record must include the recipient's name, Medicaid ID# and current category, date and time of medical appointment, date of check issuance, the provider's name and address, and mileage and amount to be authorized.

Checks should be made payable to the recipient when possible, regardless of whether the recipient is transporting himself or paying someone else to transport him. If the recipient is a minor or otherwise incapacitated, the check should be made payable to the parent, guardian, foster parent, or other party responsible for the recipient and his travel. However, the record should reflect information regarding the recipient who receives the transportation services, as specified above.

A DCO-58 must be completed and keyed to ACES each time transportation funds are issued. The DCO-58 should be filed in the recipient's transportation folder.

The job classification of the person issuing checks, keeping records and keying DCO-58s will vary from office to office. However, in all offices, the DCO-58 should be signed by a County Office Worker and the County Office travel supervisor or designee. In some offices, a County Office Worker may be the designee of the travel supervisor. In that case, only the signature of the County Office Worker is needed.

The County Office may solicit and register volunteers when necessary.

A volunteer is an individual who agrees to provide transportation upon request of the County Office. Volunteers will be utilized when other means of transportation are not available or are more expensive.

An individual registered as a volunteer must be on call and willing to transport Medicaid recipients when requested.

Registered volunteers may recruit Medicaid recipients who are in need of transportation services.

If a volunteer is a member of the recipient's family and the recipient is to be transported by that volunteer, the case record must reflect that use of the volunteer is the least expensive means available.

Foster parents will be considered volunteers when transporting children in their care. It will not be necessary to register foster parents as volunteers unless

they request reimbursement for transporting other recipients.

The recipient will be responsible for providing verification of the medical appointment. Counties should educate recipients about their responsibilities regarding verification of appointments and should make every effort not to assume this responsibility for them.

When a client cannot provide verification (provider does not schedule appointments, recipient is making initial visit, etc.), his statement will be accepted as verification. Postverification of the visit will be required at his next request for transportation.

If a recipient has twice been unable to verify in advance his appointments and the county has accepted postverification of the appointments, no further transportation funds will be issued to the client until he can provide verification of the appointments in advance.

Medicaid transportation will not be postauthorized from county bank funds. Transportation from bank funds is always authorized and paid in advance, with the exceptions of reimbursement for emergencies or suspected cases of misuse.

Volunteers, foster parents and DCFS workers must provide the same verification that is required of all Medicaid transportation recipients. Verification may be provided with submission of the TR-1s rather than each time they plan to transport a recipient for medical care. Preferably, the verification should be on the provider's preprinted letterhead, prescription pad or appointment card, with the recipient's name and date of service. The verification should be filed in the recipient's record.

Volunteers, foster parents and state employees may be reimbursed by TR-1 after the provision of transportation services.

If a volunteer limits his availability to provide transportation, reimbursement by TR-1 is not allowed. In lieu of TR-1 reimbursement, bank funds will be used at the rate of $.09 a mile.

If a volunteer is also a recipient and is transporting himself to a medical provider for medical services, reimbursement by TR-1 is not allowed.

When a DCFS employee is to be reimbursed by TR-1 for Medicaid travel, it is the joint responsibility of the DCFS travel supervisor and the DCFS supervisor to assure that Medicaid mileage claims are accurate and prepared according to policy and guidelines.

Medicaid travel should be itemized on a separate TR-1 for DCFS workers, and should never be commingled with other DCFS travel.

The DCFS supervisor should initial the TR-1 to indicate the form has been checked for accuracy and approved and that the appropriate verification of medical visits is attached. Before signing the TR-1, the DCFS travel supervisor must do the same. The final responsibility lies with the DCFS travel supervisor.

Generally, one TR-1 will be used to reflect all trips made by a volunteer, foster parent or DCFS worker during a given month. However, the county travel supervisor may authorize the use of more than one TR-1 during a month if necessary. The following information will be indicated in the upper right corner of the TR-1: "Medicaid"; and appropriation, activity, section, unit and program codes. Entries will then be made in sequence on the form as follows: name of recipient, case number, category, name of provider, name of city transported from, name of city transported to (and return, if applicable) and number of miles.

Example: 9-9-94, John Smith, 1234567-001, AD-MN, Jim Jones, MD, Sherwood to Little Rock & Return, 20 miles.

When bank funds are issued for transportation, the recipient will be informed that the check is to be used for the authorized trip only.

When it appears that a recipient has misused Medicaid transportation by making requests for transportation funds too frequently, obtaining funds but failing to keep appointments, etc., the county should investigate to determine actual misuse has occurred.

When misuse can be documented, the county will initiate the following controls:

1. Issue checks to cover only one trip at a time, and

2. Preverify and postverify appointments.

When it has been documented that misuse has occurred because the recipient did not use a bank fund check to secure medical services as authorized, an over-payment has occurred. Refer to [MS 8000] section.

If the County Office receives information indicating enrolled transportation providers are billing for transporting a recipient for whom bank funds were issued on the same date of service, the Utilization Review Section should be notified (682-8347). Dual payment for the same trip constitutes a duplication of services and misuse of the program by the recipient and the provider.

In all cases when recipients abuse/misuse transportation benefits, the Utilization Review Section will be notified. The section will make a determination concerning whether the recipient should be placed in the Recipient Education/Lock-In Program.

If a transportation check is reported lost or stolen, the county should accept the recipient's word and issue another check unless the recipient has a history of misuse of transportation funds. In that case, postauthorize and postissue the travel after proof that a medical visit was made. When making the monthly bank fund reconciliation, counties should watch for the checks reported lost or stolen.

If a medical visit is canceled after a recipient arrives at a medical facility, the county may authorize for the recipient to go to a rescheduled visit.

If a recipient cancels a visit after transportation funds have been issued and uses the money for something else, funds should not be issued to this recipient until after the next medical visit is authorized (i.e., postauthorize and postissue funds for the rescheduled visit). The first issuance which was not utilized for transportation should be treated as an overpayment.

County offices may authorize transportation to recipients who live in adjoining counties if the issuing county is more convenient for the client due to distance.

Additional bank funds may be requested by memorandum to the Administrator, Accounting Section, Division of Administrative Services, P. O. Box 1437, Slot 3205, Little Rock, AR 72203.

When bank funds are near depletion and there is knowledge that it will take several days to replenish them, existing funds cannot be reserved for individual clients. Funds will be dispersed on a first come, first serve basis.

Each Economic Services Supervisor must establish procedures to insure coordination between Medical Services Programs, Financial Assistance, Food Stamps, Services, and Child Support Enforcement Programs at the County Office level. This will include the exchange of information between County Office personnel on persons receiving benefits under more than one program, and the referral of persons applying for or receiving benefits under one program to any other program for which he may be eligible.

Upon reasonable notice to the county and during county office hours, an applicant or recipient has the right to view and/or obtain copies from his case record.

Generally, information concerning an applicant or recipient will not be released to other parties without the individual's written consent. Information may be released without an individual's written consent to:

1. Authorized employees of the Agency, the Social Security Administration, and the Department of Health and Human Services;

2. The individual's attorney, legal guardian or someone with power of attorney;

3. An individual who the recipient has asked to serve as his representative AND who has supplied confidential information for the case record which helped to establish eligibility (i.e., bank statements, income verification);

4. A court of law, when the case record is subpoenaed.

Confidential information should not be released over the telephone unless county workers are assured that they are talking with individuals who are entitled to the information being requested.

The fact that a person's name is in the authorized representative space on a DCO-95 or DCO-777 does not necessarily mean that he is an authorized representative or that information should be released to him. For example, if an AAA employee helps an elderly person complete an application and the employee puts his name in the authorized representative blank, information should not be released to this person unless requested by the applicant/recipient. If the applicant/ recipient is incapacitated, if the person who completed the application has supplied information for the case record, and if the person has a need to use information in that record to act in some capacity for the benefit of the applicant/recipient, then information can be released.

An authorized representative may change, i.e., the authorized representative who helped to establish original eligibility may not necessarily be the same person who will help reestablish eligibility at reevaluation. For example, if a NF administrator completes the DCO-777 at reevaluation and the original representative was the recipient's daughter, the recipient and/or daughter should be contacted to determine if the daughter will continue to act as representative to reestablish eligibility.

Medical records and the DCO-109 are a part of an applicant's or recipient's case record and, as such, will be considered according to [MS 1330]. At county discretion, medical records may be destroyed after receipt of the DCO-109 from MRT. However, the DCO-109 must remain in the case record as proof of the disability determination made by MRT.

If a provider furnishes an individual's full name (including middle initial), date of birth, Social Security Number, and date of service, the County Office may release limited information. Information which may be released is limited to Medicaid ID #, beginning date of eligibility, whether or not a recipient was eligible on a specific date, services for which an individual is eligible, and TPL information (including policy numbers and type of coverage, if known). It will be an administrative decision whether or not time and staff are available to provide the information.

Collateral information (evidence provided by persons other than the applicant/ recipient or by written documents) will be obtained only when necessary to establish eligibility. The applicant or recipient will be informed that the collateral will be contacted.

The County Office Worker will protect the rights of the applicant/recipient during collateral interviews, and will give only the information necessary to enable the collateral to understand the need for the information requested.

AABD category Medicaid case records may be destroyed when the case has been closed continuously for a period of three years.

AFDC and U-18 category Medicaid case records may be destroyed when:

1. The case has been closed continuously for five (5) years or,

2. The case has been closed continuously for three years and the youngest child is over 18 years old.

Exception: If an audit by or on behalf of the Federal Government has begun but is not completed at the end of the three or five year period, or if audit findings have not been resolved at the end of the three or five year period, the records will be retained until resolution of the audit findings. (Central Office will notify the County Office when an audit by the Federal Government is to be conducted, of the cases to be audited, and when the audit has been completed.)

When records or contents of case records (refer to retention schedule, DHS-PUB-014) are to be discarded, they will be destroyed by burning or shredding. These methods will maintain the confidentiality of records by ensuring that unauthorized persons do not gain access to the records.

An inmate of a public institution is not eligible for Medicaid.

Federal regulations at 42 CFR 435.1009 define a public institution as an institution that is the responsibility of a governmental unit or over which a government unit exercises administrative control. This control can exist when a facility is actually an organizational part of a government unit, or when a governmental unit exercises final administrative control. Public institutions include county jails, state and federal penitentiaries, juvenile detention centers, and other correctional or holding facilities. Wilderness camps and boot camps are considered public institutions if a governmental unit has any degree of administrative control.

Federal regulations at 42 CFR 435.1009 define an inmate as an individual living in a public institution.

An individual who is an inmate in a penal or correctional institution is not Medicaid eligible, because the State or other governmental authority, by the act of incarceration, has assumed full responsibility for his/her care. If the inmate must be temporarily transferred to a medical treatment or evaluation facility, or if he/she is given temporary furlough, the individual is still considered an "inmate" under custody of the penal or juvenile justice system and is excluded from the Medicaid program.

Inmate status will continue until the indictment against the individual is dismissed or until he/she is released from custody either as "not guilty" or for some other reason (bail, parole, pardon, suspended sentence, home release program, probation, etc.).

As a condition of eligibility for Medicaid, recipients are required to assign their rights to Medical Support/Third Party Liability payments to the Division of Medical Services. This means that any funds settlements, or other payments made by or on behalf of third parties should be paid directly to the Arkansas Medicaid Program. In Arkansas, Third Party Liability payments are automatically assigned by state law.

The Medical Assistance Program is required by Federal and State Regulations to utilize all Third Party sources and to seek reimbursement for services which have been paid by both a Third Party and Medicaid.

Private insurance and Medicaid are complementary. A recipient's Medicaid eligibility is not affected by having Third Party coverage.

When a recipient has Third Party coverage in addition to Medicaid which can be used for medical expenses, Third Party coverage must be utilized first. Medicaid will pay up to the Medicaid allowable charge. For example: A Medicaid recipient has insurance which paid 80%, or $80 of a $100 medical bill. The Medicaid allowable charge for the bill was only $60.00. A Medicaid payment was not due since the Medicaid allowable charge was less than the insurance payment. Third Party sources whose payment Medicaid will retrieve include private health insurance, automobile liability insurance where applicable, workmen's compensation, settlements for injuries, etc.

The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) is considered to be a Third Party source. Whenever a CHAMPUS beneficiary is also eligible for Medicaid, CHAMPUS is in every instance the primary payor. This applies to all classes of CHAMPUS beneficiaries, i.e., dependents of active duty members, retirees, dependents of retirees, dependents of deceased active duty members, and dependents of deceased retirees.

Third Party resources (if any) will be determined by completing the DCO-662 at the time of application and at each reevaluation when Third Party coverage is reported by the applicant/recipient. Third Party resources will be indicated on the DCO-56 or DCO-57, whichever is applicable.

Third Party information will be indicated on the TPL field on the DCO-56 or DCO-57 and consists of an alpha code. Refer to forms instructions for the applicable code.

NOTE: For cases involving CHAMPUS, the name and Social Security Number of the service member must be entered on the DCO-662. The CHAMPUS address is P.0. Box 17304, Tucson, AZ 85731-7304.

Upon determining that Third Party coverage exists, inform the recipient of the restrictions placed on the coverage by the Medicaid Program, (i.e., recipients are not entitled to any benefits and/or compensation from Third Party sources on services for which Medicaid has made or will make compensation). Instruct recipients who want Medicaid billed for services that they are to assign their TPL resource benefits to the provider before services are rendered.

Recipients are not entitled to any benefits and/or compensation from Third Party sources on services for which Medicaid has made or will make compensation. For this reason, recipients are responsible for assigning the TPL resource benefits to the provider before services are rendered if they want Medicaid billed for the services. This includes indemnity policies such as cancer policies, intensive care policies, etc.

If the provider elects not to accept Medicaid on the recipient, the recipient becomes a "private pay" patient and is responsible for the full cost of services rendered. Assignment is not required for non-Medicaid claims.

If Medicaid has established the probable existence of third party liability at the time the claim is filed, the agency must reject the claim and return it to the provider for determination of the amount of liability.

It is the responsibility of the provider to file a claim for services with Third Party sources and to report the third party and receipt of funds received from the third party when filing a Medicaid claim.

When the amount of liability is determined, Medicaid will pay the claim to the extent that payment allowed under the agency's payment schedule exceeds the amount of the third party's payment.

The provider is to make no claims against a Third Party source for services for which a claim has been submitted to Medicaid.

Recipients who are not cooperating with the Division of Medical Services Third Party Liability Unit will be subject to termination of Medicaid assistance. The Third Party Liability Unit will notify the County Office when a recipient has been determined uncooperative.

When a notice is received from the Third Party Liability Unit that a recipient is not cooperating, the Service Representative will:

1. Complete Form DCO-700 or DCO-1, as appropriate, to give advance notice to the recipient that his Medicaid will be terminated due to failure to cooperate.

2. For single member cases, complete DCO-57 to process a close action, effective the date advance notice expires. Use code 059 for this action.

3. For family Medicaid cases, complete an other "0" action on Form DCO-56, using action reason 003 and close the adult member on WAFM effective the date advance notice expires. Use code 059 to close an adult member.

If the adult has countable income used in determining eligibility, key a "Y" to the Budget Indicator Field.

4. For AFDC Grant or No-Grant cases, complete Form DCO-56 to enter the Medicaid End Date for the adult member only. Leave the adult member status open so that the adult's needs will continue to be included in the case.

The recipient who has not cooperated with the Third Party Liability Unit will remain ineligible for Medicaid until that unit determines that the recipient is cooperating. The Third Party Liability Unit will notify the County Office when a case or member can be reopened.

Public Law 99-509, the Omnibus Reconciliation Act of 1986, prohibits a State from denying any individual Medicaid benefits who does not have a fixed or permanent address, but who resides in the state and is otherwise eligible.

If the applicant is considered an Arkansas resident and meets the other requirements for eligibility, the case may be certified using the address of choice for the applicant.

When a Medicaid application is approved on ACES or an SSI case is transmitted to the ACES system via SDX, the system will determine if a photo is required on the recipient's Medicaid Identification Card. If the recipient is required to have a photo, the system will issue form DCO-922 to the recipient within 4 days of the certification instructing the recipient where to have his/her photo made. Form DCO-922 is issued to all new approvals requiring a photo on their ID card. Recipients who reside in Benton, Craighead, Crittenden, Garland, Jefferson, Mississippi - I, Phillips, Pulaski I and II, Sebastian, and Washington Counties will take the form to the DHS County Office to have their photo made and to get their Medicaid ID Card. Recipients who reside in any other county will take the form to their local Revenue Office. The Medicaid Identification Card will be issued on the day that the photo is made.

Children under the age of five, Long Term Care and Waiver recipients are not required to have their photo on the Medicaid ID Card. The system will automatically produce a "Valid without Photo" Medicaid ID Card and the DHS Central Office Client Assistance Unit will mail it to the recipient within 3 or 4 days after approval on ACES.

There may be instances when the county office worker will need to override the photo determination by the system. For those recipients who require a photo but who are unavailable to be photographed (i.e., bedfast, recipient now lives out-of-state or is deceased), the county office worker will complete form DCO-135 to be keyed to the ACPH screen. An "N" will be keyed in the Photo Exception Field. The system will produce a "Valid without Photo" Medicaid ID Card. When recipients are not required to have a photo but the county office has determined that one is needed (i.e., Waiver recipient requests a photo), a "Y" will be keyed in the Photo Exception Field on ACPH via the DCO-135. Form DCO-922 will be issued instructing the recipient where to go to have the photo made.

The following information is imprinted on the card:

1. Identification Number - The Medicaid Identification Number is a ten digit number (e.g., 0123345-001).

2. Name of Eligible Recipient

3. Birthdate

4. Date of Issuance - Identifies the date the Medicaid card was originally issued.

The recipient is responsible for presenting his/her Medicaid Identification Card to the hospital/physician for billing purposes each time he/she receives a service.

NOTE - The recipient should be instructed to keep his Medicaid card even after an eligibility period has ended, as he will need it should he become eligible again in the future.

The County Office has the capability to issue duplicate Medicaid cards if the recipient reports non-receipt of a Medicaid card or requests a replacement due to loss, theft or destruction of the original. The procedures are the same for SSI and non-SSI recipients.

1. Review recipient's case record to verify that correct information has been keyed. Submit a corrected DCO-56 or DCO-57, if applicable (See "Note" under #2 and 3).

If the recipient is SSI eligible, inquire to the cross-reference screen (WSSN) to locate the SSI case number. If there is no record of a case, or the SSI recipient is not receiving a check, refer him/her directly to his local SSA Office. If the SSI recipient has been certified for 30 days or less, inform him/her that it is too early to have received a Medicaid card. It takes Social Security 30 days or more from the date of approval to forward the eligibility data via SDX.

2. Inquire to the WRMC screen to determine if the Medicaid ID card has been returned to Client Assistance. If the card has returned, the county can authorize Client Assistance to release the card by updating WRMC and keying a "Y" in the Release Field. A mailing label and printout will be generated to Client Assistance the following day. Client Assistance will release the card upon receipt.

Note: The DCO-56 or DCO-57 must be keyed prior to releasing the card on WRMC.

3. If the ID card has not been returned to Client Assistance, inquire to the WIDC screen to determine the issuance date. Complete form DCO-135 to be keyed to WIDC for reissuing. All reissued cards requiring a photo will use the photo already stored on file unless the worker determines that a new photo is required (i.e., last photo developed at age 6, child now 12). The county office worker will have a "P" keyed in the Photo Exception Field. The recipient will be issued form DCO-923 instructing where to have the new photo made. If the client is now required to have a photo taken but in the past did not have a photo (e.g., child who was age 4, is now age 6), the system will automatically determine that a photo is now required and will generate Form DCO-922 instructing where to have the photo made. If the new ID card should be issued without a photo (recipient is now in a nursing home), the system will automatically issue a "Valid without Photo" card.

Note: The DCO-56 or DCO-57 must be keyed prior to reissuing the card on WIDC if corrections are needed.

4. If there is no issue date on WIDC, contact ACES System Support.

5. If the SSI case record is located on WSSN, but information on the record is incorrect (e.g., wrong address), contact ACES System Support or Client Assistance.

Medicare is a Federal Insurance Program which pays part of hospital and medical costs for persons 65 years of age and over, certain disabled persons, and others determined eligible by the Social Security Administration. Medicare Insurance in Arkansas is processed by Arkansas Blue Cross and Blue Shield. Medicare consists of 2 types of coverage, Part A - Hospital Insurance and Part B - Medical Insurance.

Part A - Hospital Insurance is available to certain eligible Medicare recipients without cost; other individuals, age 65 and over may purchase Part A for a premium. Part A provides hospital insurance coverage for inpatient hospital care, post-hospital extended care and post-hospital home health care. The Agency purchases this coverage for individuals entitled as Qualified Medicare Beneficiaries and Qualified Disabled Working Individuals who must pay the Part A premium (Re. [MS 2047 - 2047.11 and MS 2048-2048.7]).

Part B - Medical Insurance for persons eligible for Medicare and Medicaid (with the exception of Medically Needy Spend Down) and for Specified Low Income Medicare Beneficiaries (Re. [MS 2051-2051.6]) is purchased by the Agency. Medical Services include physician services, supplies, home health care, outpatient hospital services, therapy, and other services.

Limitations for recipients with joint Medicare/Medicaid coverage:

1. Medicaid pays Part B deductible and coinsurance of allowable charges on assigned Medicare claims filed by a participating provider. Medicare determines covered services and allowed charges on all joint claims. Medicaid benefit limits do not apply to Medicare allowable services under Part B.

2. Medicaid covers all medically necessary days of hospitalization. This coverage may be in the form of deductible, coinsurance, and/or per diem payments.

3. Medicaid participates in payment of extended care and skilled nursing care coinsurance days which are allowed by Medicare.

The Division of Medical Services pays Medicare Part B premiums for eligible Medicare-Medicaid recipients on the basis of their Medicare claim number supplied by the County Office on Form DCO-57. For recipients who report that the premium is still being deducted from their monthly Social Security check, the County Office will complete Form DCO-53, Report of Buy-In Problem Cases and mail to the Income Support Section, Attention: Buy-In Coordinator.

As a condition of eligibility, all Medicaid recipients are required to cooperate with the Quality Assurance (QA) Unit during their review process.

Upon notification from a QA reviewer that a Medicaid recipient has refused to cooperate, the County Office Worker will send a 10-day notice to the recipient stating that the Medicaid case will be closed for failure to cooperate with the QA reviewer. The notice will also specify that the family will be ineligible until the client cooperates with the QA reviewer.

Exception: A newborn case (category 52 or 63) cannot be closed because of the parent's failure to cooperate with QA.

            To meet the Social Security enumeration requirement, each eligible person included in the Budget Unit must either:

            a.         Declare a Social Security number or

            b.         Apply for a Social Security number if one has not been issued or if one has been issued but is not known.

1. Individuals who Declare an SSN

            To declare an SSN, an individual must state the number.  Verification is not required.  When an individual declares an SSN, the eligibility worker will enter the SSN to the ANSWER system for verification through the IEVS system.  (This verification process is described in MS 1390 #5.) The county office worker will not attempt to verify the SSN declared.  However, if the household presents documentary evidence such as a social security card, a copy will be placed in the case record and used, if necessary, to clear any SSN discrepancies. 

2.  SSN Application Process (No SSN or SSN Not Known)

a.        a.   Aliens and Individuals age 12 or over 

An alien regardless of age and an individual age 12 or over must apply in person at the local Social Security Administration Office.  The eligibility worker will issue an SS-5, Application for a Social Security Card and a DCO-12, Enumeration Referral, along with the identifying information and pseudo-SSN to the applicant. The worker will not forward any evidence to SSA for the applicant unless SSA specifically requests such evidence.  A photocopy of the SS-5 and DCO-12 will be retained in the county office until the DCO-12 is returned by SSA showing that a complete SSN application has been received.  

An individual who has been issued a number but does not know it can obtain a replacement SSN card by completing an SS-5 and taking or mailing it to SSA.

If the DCO-12 is returned by SSA showing that a complete SSN application has not been received, the eligibility worker will send a DCO-700 advising the applicant that he must submit a complete SSN application to SSA within 10 days or the Medicaid application will be processed without that person’s eligibility being considered.

a.                 b.  Individuals under age 12

Form SSA-2853 (Receipt for Enumeration at Birth) will be accepted as proof of application for an SSN if an application for an SSN was made at the hospital when the baby was born.  The eligibility worker will request the applicant to provide the SSA-2853, and make a photo copy for the case record.  The county worker can accept this form as proof until the first reevaluation for continued eligibility.  At that time, if a card has not been received, or a number is not on the system, the worker will complete an SS-5 and DCO-12 to forward to the SSA office, as described below.

For other individuals under age 12 who must apply for an SSN, the eligibility worker must complete the SS-5 and DCO-12.  The worker will inform the applicant of what are acceptable types of evidence to verify date of birth, identity and U.S. citizenship as listed on the SS-5 application.

The original copies of evidence along with the SS‑5 and DCO-12 will be submitted to the local Social Security Administration Office.  A photocopy of the SS‑5 and DCO-12 should be retained in the county office until the DCO-12 is returned by the SSA office indicating that a complete SSN application has been received.

                        If the DCO-12 is returned by SSA indicating that additional information or evidence is required, the worker will obtain the additional evidence, if available to the worker, and resubmit the entire SSN application and DCO-12.  If additional evidence is not available to the worker, a DCO-700 will be sent to the applicant requesting the information and advising that if not provided within 10 days, the application will be processed without the person's eligibility being considered.

a.                   c.  Qualified Aliens not Authorized to Work in the U.S.

    SSA will not assign an SSN or a replacement card to an alien who does not have

    authorization of the Department of Homeland Security to work in the United States

     unless the alien has a valid non-work reason for needing an SSN.  Meeting the

     eligibility requirements for Medicaid, in a category where an SSN is required of 

     eligibles, would be a valid reason for SSA to authorize an SSN.  To assign an SSN 

     in this situation, SSA requires documentation from DCO that the individual meets all

     eligibility requirements for Medicaid except for an SSN.  For these individuals, the

     county office must first determine that the individual meets all points of eligibility

     except for an SSN.  If they are Medicaid eligible, the county should complete the

     DCO-12, checking on the form that the non-work alien meets all eligibility

     requirements except for the SSN.  The county office will issue the DCO-12 and SS-5

     to the applicant or responsible party, following the procedures in 2.a. above,

     regardless of the age of the qualified alien.  SSA requires an interview for

     enumeration of all non-citizens.  NOTE:  Counties should only refer eligibles to SSA

     Non-eligible, non-work alien parents applying only for their children should not be

     referred to SSA.  They should be given a pseudo-SSN.

d.   Undocumented Alien

          An undocumented alien who is the casehead or included as an ineligible member in an open case will be assigned a pseudo number even if an SSN is provided.  This includes an undocumented pregnant woman. More information regarding the procedures for applying for a SSN can be obtained through  SSA’s website: www.ssa.gov/ssnumber/ or by calling toll free at 1-800-772-1213, deaf or hard of hearing at 1-800-325-0778 from 7 a.m. to 7 p.m., Monday through Friday for specific questions.

3. Exemption from the SSN Requirement

     Only those eligible in the Newborn Infant Categories and aliens eligible under emergency provisions including SOBRA coverage for ineligible aliens are exempt from the enumeration requirement.  However, since most newborns are “enumerated at birth”, a pseudo number assigned to the newborn will be updated in ANSWER when an SSN is received.

4.  Non-Eligibles Included In the Standard of Need

Non-eligible minor children, parents and other caretaker relatives, who are in the degrees of relationship to be included in the standard of need, may be included in the needs standard without enumeration.  Every effort should be made to secure the SSN of non-eligibles in the standard of need, but eligibility cannot be denied or delayed for eligible individuals based on non-enumeration of non-eligibles.

5. Verification of Social Security Number by SSA

            Each month all Social Security numbers that have been entered to ANSWER  by the county office with enumeration code "Provided" are submitted to the Social Security Administration to verify SSN based on name, sex and date of birth.  ANSWER will submit every unverified number and pseudo numbers on a monthly basis.  If all match data agrees with SSA records, the enumeration code is changed to "Verified" in ANSWER by the system and the SSN is no longer keyable by the county.  Once verified the enumeration code “S” will show on the Mainframe and ANSWER will show verified.

            If one or more of the match items does not agree with SSA records, the enumeration code will be changed on the Mainframe and ANSWER system to one of the following mismatched codes:

             Mainframe                             ANSWER

                        1                                  SSN not on SSA files

                        2                                  Name matches, DOB matches, Sex does not match

                        3                                  Name matches, DOB does not match

                        4                                  Name matches, DOB and Sex do not match

                        5                                 Name does not match, DOB and Sex not checked.

                        6                                  Name and DOB match, multi or different SSN

6.   SSN Mismatch Report

       SSNs that have mismatched with SSA records will be reported via the SSN Mismatch Report on the ANSWER Reporting System.  A mismatched SSN will continue to appear on this report each month until the mismatch has been resolved and SSA verifies the number.  The report will reflect the number of times a particular mismatched SSN has been submitted to SSA.  This counter will appear in the “Counter” column of the Mismatch Report.