IM-#34, March 12, 2019, IM-#19, February 07, 2018
To initially qualify for Transitional MO HealthNet, a household must:
NOTE: The increased earned income may come from a parent or caretaker relative who was added to the case as their needs and earned income are used to complete the budget.
EXAMPLE: Ms. Purple and her children have received MHF for the past year. Ms. Purple marries Mr. Grey and he is added to the household. Since his needs and earned income are now used to complete the budget, Ms. Purple and the children are now eligible for TMH. Mr. Grey is not eligible for TMH since he has not received MHF in three of the last six months.
The participant’s self-attestation of increased earnings or employment and the date employment began may be accepted. If verification is requested (combination MHF/Temporary Assistance case) but not received, determine eligibility for Transitional MO HealthNet based on the self-attestation of the household (In MEDES this is the MHF to TMH verification code).
If more than one change occurs that could cause MHF ineligibility, use the change occurring first to determine eligibility for Transitional MO HealthNet.
Federal law (42 U.S.C. 1396r-6) makes Transitional MO HealthNet mandatory for states.
Section 208.151.3 (RSMo 1990) provides for Transitional MO HealthNet as follows: After April 1, 1990, any family receiving aid pursuant to 42 U.S.C. 601 et seq, as amended, in at least three of the six months immediately preceding the month in which such family becomes ineligible for such aid, because of hours of employment or income from the parent/caretaker relative’s employment, remains eligible for medical assistance for six calendar months following the month of ineligibility as long as such family includes a child as provided in 42 U.S.C. 1396r-6. Each family receiving such medical assistance during the entire six-month period described in this section and that meets reporting requirements and income tests established by the division and continues to include a child as provided in 42 U.S.C. 1396r-6 receives medical assistance without a fee for an additional six months. MO HealthNet Division (MHD) may provide by rule the scope of MO HealthNet coverage granted to such families.
Effective February 1, 1999 Missouri began providing two years of extended TXIX coverage to uninsured adults who successfully complete the 12 months of Transitional MO HealthNet (TMH) on or after January 31, 1999. A Medicaid waiver under Section 1115 of the Social Security Act authorizes this coverage.
Effective July 1, 2002 Missouri House Bill 1111 reduced the extended TXIX coverage for uninsured adults to 12 months.
Effective July 1, 2005 Missouri House Bill 11 eliminated the extended TXIX coverage for uninsured adults.
In June of 1999, Missouri began referring to the Medicaid program for all family eligibility groups as MC+.
Effective September 1, 2007, the Missouri Health Improvement act of 2007, Senate Bill 577 changed the name of Missouri Medicaid to MO HealthNet.
Effective April 16, 2015, the federal government approved Public Law 114-10 section 212 which granted a permanent extension of transitional medical assistance.
The following definitions apply to Transitional MO HealthNet:
The parent or caretaker relative may claim the child as a dependent on income taxes, but is not required to do so.
NOTE: If a household member receiving TMH gives birth during the Transitional MO HealthNet period, that member's child is eligible for automatic newborn coverage.
Below are two uses of Good Cause with TMH and the acceptable reasons:
A household meeting criteria for initial Transitional MO HealthNet eligibility is eligible for the first six months unless:
Failure to complete and return the first quarterly report form without good cause results in ineligibility for Transitional MO HealthNet for the second six months. See Quarterly Report Requirements. Always explore eligibility for other MO HealthNet programs any time TMH eligibility ends.
To initially qualify for Transitional MO HealthNet, a household must:
The participant’s self-attestation of increased earnings or employment and the date employment began may be accepted. If verification is requested (combination MHF/Temporary Assistance case) but not received, determine eligibility for Transitional MO HealthNet based on the self-attestation of the household.
If more than one change occurs that could cause MHF ineligibility, use the change occurring first to determine eligibility for Transitional MO HealthNet.
Households must have been eligible and received MHF in at least three of the last six months immediately preceding the first month of MHF ineligibility. The household must have met all MHF eligibility criteria in the three months and been approved for MO HealthNet coverage on that basis.
NOTE: Because TMH can start on any given day of the month, partial months may be counted towards BOTH the 3 out of 6 required months of MHF AND the first month of TMH. For example, TMH begins on April 17th. April counts as a MHF month and a TMH month.
Months of prior quarter MHF may be included in the three months needed to establish eligibility for Transitional MO HealthNet. Households ineligible for MHF in the month of application due to the reasons in manual section 1820.030.00 Eligibility for Initial Six Months, but eligible for all three Prior Quarter months may receive Transitional MO HealthNet. In this situation, approve the application beginning MHF coverage at the earliest date eligibility existed in the prior quarter.
EXAMPLE 1: Mr. White applied for benefits on March 4th and requested Prior Quarter coverage. He started a new job on February 20th and received his first check on March 1st. After reviewing his income, Mr. White is not eligible for MHF coverage in March. Mr. White did not have any income in the months of December, January, and February, and is eligible for MHF in those months. Because he is eligible in at least three of the last six months, his household qualifies for TMH starting March 1st. Approve MHF beginning on December 1st.
Transitional MO HealthNet eligibility begins as soon as the adverse action period stating ineligibility for MHF expires.
EXAMPLE 2: On July 25th Ms. Green reported she went to work on July 21st. Ms. Green is a parent/caretaker relative whose earnings cause ineligibility for MHF. To stop MHF eligibility a 10-day adverse action notice is necessary. If Ms. Green received MHF in three months during the period of March through August, she is eligible for TMH. Change was reported July 25th and FSD mailed the adverse Action Notice the same day. The Adverse action period ends on August 4th. Ms. Green begins receiving TMH the day after the Adverse Action expires – August 5th.
EXAMPLE 3: Ms. Brown and her family have received MHF since April of the previous year. They were due for a review a year later in April. The review was attempted without contact with the participant. Income verification via electronic data was inconclusive and an IM-31A Request for Information was sent requesting income verification. Verification was not provided and MHF closed April 30th. Ms. Brown reapplied May 10 and provided the necessary income verification. Because she provided the verification within 30 days of the closing date we can reopen her original case and process it for TMH (refer to 1885.030.00 Reopening Closed Cases). No new application is necessary.
EXAMPLE 4: Mr. Blue and his family were placed on MHF in March. It is now August and Mr. Blue is reporting a job he started on April 2nd. The first day that Mr. Blue’s family could have received TMH coverage would be April 22 (Allowing 10-days from start of job to report change and 10-days for Adverse Action period). Since the family’s MHF coverage started in March and they would have moved to TMH in April, they do not meet the eligibility guideline of receiving MHF in three out of the last six months. The Blue family is not eligible for TMH. Complete an ex parte review of all household members.
NOTE: Each Prior Quarter month has its own independent evidence for the following: Prior Quarter Income, Prior Quarter Deductions, and Prior Quarter Medical Bills.
When a household is no longer eligible for MHF, but qualifies for TMH, send an Adverse Action Notice (IM-80) to notify the family of its right to extended MO HealthNet for Families. It is required to include with the notice reporting requirements and circumstances under which the extension may be terminated. An electronic version of What You Need to Know About Transitional MO HealthNet (IM-4 TMH) is found in the forms manual and should be mailed with the IM-80.
A household meeting criteria for initial Transitional MO HealthNet eligibility is eligible for the first six months unless:
Failure to complete and return the first quarterly report form without good cause results in ineligibility for Transitional MO HealthNet for the second six months. See Quarterly Report Requirements. Always explore eligibility for other MO HealthNet programs any time TMH eligibility ends.
The start date for TMH will always be calculated as the date the coverage should have begun (NOT the date of discovery).
When the change is reported/discovered before the 21st day of the fourth month of Transitional MO HealthNet eligibility, enter the income change as reported by the participant and MEDES will take the appropriate action.
EXAMPLE 1: Ms. Black and her family have been on MO HealthNet for Families since September. It is now the following June and Ms. Black just reported that she started a job on March 24th. We cannot affect her coverage for the month of March. Using March 24th as our starting point, allowing ten (10) days for Ms. Black to report the change, ten (10) days for FSD to process the information, and another ten (10) days for an adverse action, the first date that Ms. Black’s family could receive TMH coverage would be April 23rd. April counts as her first month of TMH.
When the change is reported/discovered after the 21st day of the fourth month but before the end of the sixth month of Transitional MO HealthNet eligibility, complete a closing transaction providing Transitional MO HealthNet for the first six months only. DO NOT give or send the parent/caretaker relative a quarterly report form. The due date passed and the caretaker cannot be eligible for the second six months. Explore eligibility for other MO HealthNet programs.
EXAMPLE 2: Ms. Orange and her family were placed on MHF 12 months ago (in February). It is now January and Ms. Orange is reporting a job she started on August 12th. Using August 12th as our starting point, allowing ten (10) days for Ms. Orange to report the change, ten (10) days for FSD to process the information, and another ten days for an adverse action, the first date that Ms. Orange’s family could receive TMH coverage would be September 11th. January would count as her fifth month of TMH. Since Ms. Orange did not report her income until after the first quarterly report would have been due (by the 21st day of the 4th month/December 21st), her household is only eligible for the first six months of coverage and no extended coverage.
p>When the change is reported/discovered after the end of the sixth month of Transitional MO HealthNet eligibility, follow appropriate closing procedures on the MHF case and do not transfer to Transitional MO HealthNet. Enter a complete comment in MEDES explaining why TMH was not entered into system. Explore eligibility for other MO HealthNet programs prior to closing the MHF case.EXAMPLE: Ms. Crane and her family have received MHF for 9 months. Ms. Crane started a new job on January 20th; however, she did not report the new income to FSD until after August 3rd. Using January 20th as our starting point, allowing ten (10) days for Ms. Crane to report the change, ten (10) days for FSD to process the information, and another ten (10) days for an adverse action, the first month that Ms. Crane’s family could have received TMH coverage beginning February 19th. August would count as her seventh month of TMH. This income was reported after the sixth month (July) of possible TMH eligibility. Follow standard procedure and complete an ex parte review on all household members.
When a change is reported timely but agency does not enter the change timely, take the following actions:
When the error is discovered before the 21st day of the fourth month of Transitional MO HealthNet eligibility, give or send the caretaker the first quarterly report form. If necessary, allow a reasonable amount of additional time for the parent/caretaker relative to complete the quarterly report form. Make sure the quarterly reports are entered into MEDES so that the participant is sent the next quarterly report timely.
EXAMPLE: Ms. Donner and her family are receiving MHF. Ms. Donner started a new job on June 21st and reported the new income to FSD on June 28th. Eligibility for MHF should have ended and TMH started sometime in July; however, FSD failed to act on the change until September 30th. This information was acted upon before the first quarterly report was due to be returned (21st day of the fourth month).
When the error is discovered after the 21st day of the fourth month but before the end of the sixth month of Transitional MO HealthNet eligibility, give or send the caretaker the quarterly report form to complete for the first three months. Allow at least ten days for the parent/caretaker relative to complete the form, and reinstate coverage if necessary. Make sure the quarterly reports are entered into MEDES so that the participant is sent the next quarterly report timely.
EXAMPLE: Mr. Everly and his family are receiving MHF. Mr. Everly started a new job on March 21st and reported the new income to FSD on March 25th; however, FSD did not act on the income change until August 10th. Eligibility for MHF should have ended and TMH started sometime in April. This income was processed by FSD after the first quarterly report was due to be returned (21st day of the fourth month), but before the last day of the sixth month.
When the error is discovered after the end of the sixth month of Transitional MO HealthNet eligibility, give or send the parent/caretaker relative the necessary quarterly report forms and allow at least ten days for the parent/caretaker relative to complete the forms. Make sure the quarterly reports are entered into MEDES so that the participant is sent the next quarterly report timely.
EXAMPLE: Ms. Farr and her family are receiving MHF. Ms. Farr started a new job on February 1st and reported the new income to FSD on February 9th; however, FSD did not act on the income change until September 2nd. Eligibility for MHF should have ended and TMH started sometime in February. This income was processed after the sixth month of possible TMH eligibility.
If an individual (except the Head of Household), who is a MHF household member when the case moves to TMH, moves out of the household, is removed from the case, then moves back in, that individual can regain eligibility for Transitional MO HealthNet as long as the household remains eligible. If the case is closed because the only child leaves, or is closed for some other reason before the child returns, the household may not regain Transitional MO HealthNet eligibility for the original period.
EXAMPLE: Mrs. Johnson has three children and they all receive MHF. Mrs. Johnson started a job causing the family to no longer be eligible for MHF. After an adverse action period they are moved to TMH. A month later, Mrs. Johnson’s son (Allen, age 15) leaves the home to live with his father. Mrs. Johnson and the other children continue to remain eligible for TMH. Five months later, Allen moves back in with his mother. Because he was a member of the original approved TMH household, Allen can be placed back on TMH until the household is no longer eligible or their 12-month maximum time limit expires.
Households eligible for Transitional MO HealthNet during the entire first six month period and who complete and return the first quarterly report on a timely basis are potentially eligible during the second six month period.
Transitional MO HealthNet eligibility continues during the second six months unless:
On the second and third quarterly reports, parent/caretaker relatives report income for the second and third quarters of Transitional MO HealthNet eligibility. Accept the parent/caretaker relative’s self-attestation of income. Use the quarterly report to:
Income should be considered in the same manner shown in manual section 1805.030.00 Modified Adjusted Gross Income (MAGI) Methodology.
The household for this budget includes:
NOTE: If an individual moves into or out of a Transitional MO HealthNet household during the report quarter, include members in the household based on the situation at the end of the quarter.
If MAGI is greater than 196% of the poverty level, explore the children's eligibility under other MO HealthNet programs. The quarterly report form gives the household the opportunity to report if anyone is pregnant, blind or disabled. Complete a review based on the information available. An Adverse Action Notice (IM-80) is required when a household member:
If the household requests, prior to expiration of the IM-80, to keep coverage open until a hearing decision is made, allow the TMH to continue, pending the outcome of the hearing. Discontinue eligibility under TMH at the end of the seventh or tenth month, whichever is applicable if there is no request for a hearing.
To continue eligibility, Transitional MO HealthNet quarterly reports are sent to parent/caretaker relatives as follows:
| Quarterly Report | When mailed to Participant | Reminder mailed | Due date |
|---|---|---|---|
| First | 21st day of the third month of TMH eligibility | 12th day of the fourth month of TMH eligibility | 21st day of the fourth month of TMH eligibility unless good cause exists *Failure to return the first quarterly report by the due date results in ineligibility for the second six months, unless good cause exists. |
| Second | 21st day of the sixth month of TMH eligibility | None | 21st day of the seventh month of TMH eligibility unless good cause exists. *Failure to return the second quarterly report by the due date results in suspension of the parent/caretaker relative’s TMH eligibility until the completed |
| Third | 21st day of the ninth month of TMH eligibility | None | 21st day of the tenth month of TMH eligibility unless good cause exists. *Failure to return the second quarterly report by the due date results in suspension of the parent/caretaker relative’s TMH eligibility until the completed report is submitted. The parent/caretaker relatives are not eligible for TMH during the suspension period unless good cause for failure to report exists. |
When the quarterly report is received, determine if the report is complete, and determine if the household continues to meet Transitional MO HealthNet eligibility requirements. Consider a quarterly report complete when all questions about earnings are answered and the form is signed.
If the parent/caretaker relative had Good Cause for failing to return a completed quarterly report, reinstate the parent/caretaker relative’s TMH eligibility. Refer to definition of Good Cause at 1820.015.00 TMH DEFINITIONS #3.
If Good Cause is granted, refer to 1820.050.30.10 Reinstatement of TMH Eligibility for Six Month Closings and 1820.050.40.10 Reinstatement of Individuals Suspended On TMH.
If the first quarterly report is not received by the 21st day of the 4th month of TMH eligibility, complete an ex parte review to evaluate possible eligibility under other MO HealthNet (MHN) programs.
If any children on TMH are now eligible for a non-premium level of care, immediately change them to the new coverage and send an action notice advising the primary person on the case of the change.
If children on TMH are now eligible for a premium level of care, send Action notice advising the household that they will begin paying a premium in 60 days. Use the following manual procedure for 60-day transitional period:
If “good cause” is determined after the TMH case has closed it will be necessary to restore the TMH eligibility. Reinstate TMH as quickly as possible to prevent any disruptions in MO HealthNet coverage or enrollment in managed care whenever possible. If TMH is restored after quarterly reports are sent out, send whatever quarterly reports are due and allow the participant time to return them.
If “good cause” is not claimed or allowed, but the parent/caretaker relative contacts FSD indicating possible eligibility due to disability, pregnancy, blindness or change in circumstances, restore eligibility to TMH, pending an eligibility determination under the appropriate category of assistance. Follow the procedures in manual section 1820.060.00 EX PARTE REVIEW WHEN TMH ENDS to determine if parent/caretaker relative(s) is eligible for another category of MO HealthNet.
NOTE: If one of two parents indicates possible eligibility elsewhere, only reinstate the parent claiming other possible eligibility to TMH.
If the second quarterly report is not returned by 21st day of 7th month:
EXCEPTION: If a change is reported making a parent eligible for another level of care (for example, the parent reports being disabled and is determined eligible for MHABD), move the parent to the appropriate level of care without any interruption of coverage.
If any children on TMH are now eligible for a non-premium level of care, immediately change them to the new coverage and send an action notice advising the primary person on the case of the change.
If children on TMH are now eligible for a premium level of care, leave them on TMH until the end of the second 6-month period. Use the following manual procedure for 60-day transitional period:
If the third quarterly report is not returned by 21st day of 10th month:
EXCEPTION: If a change is reported making a parent eligible for another level of care (for example, the parent reports being disabled and is determined eligible for MHABD), move the parent to the appropriate level of care without any interruption of coverage.
If any children on TMH are now eligible for a non-premium level of care, immediately change them to the new coverage and send an action notice advising the primary person on the case of the change.
If children on TMH are now eligible for a premium level of care, leave them on TMH until the end of the second 6-month period. Use the following manual procedure for 60-day transitional period:
If there are NO children active on the TMH case at the end of the twelve-month eligibility period, close the case.
Upon receipt of the quarterly report, reinstate suspended TMH individuals.
If “good cause” is allowed reinstate back to the date of the suspension. If “good cause” is NOT allowed, reinstate effective the first day of the month following the receipt of the report.
Reinstate coverage as quickly as possible to prevent any disruption in MO HealthNet coverage or managed care enrollments. If restoring TMH eligibility from suspended status, send a quarterly report if the third quarterly report is needed.
An ex parte review must be completed to explore eligibility for other MO HealthNet programs when Transitional MO HealthNet eligibility ends. Refer to MAGI manual section 1890.000.00 EX PARTE REVIEW PROCESS. Income verification submitted for any FSD program within the previous 6 months.
When TMH eligibility is ending, an exparte review must be completed. Refer to MAGI manual section 1890.000.00 EX PARTE REVIEW PROCESS.
If a participant requests an administrative hearing to appeal the denial of eligibility for other programs, and the TMH case has not yet closed, allow the TMH case to remain open, at the participant’s request, pending a decision. Refer to manual section 0130.020.00 for further information regarding administrative hearings.