346 Targeted Adult Medicaid (TAM)

Effective Date: June 1, 2025

A. Introduction

1. Targeted Adult Medicaid offers 12 months of continuous eligibility (715) to marginalized populations, identified below.

2. TAM uses the MAGI methodology to determine countable income and household size (401 and 402).

3. TAM offers Housing Related Services and Supports (HRSS) to those chronically homeless individuals. (600)

B. Coverage Groups

1. To be eligible for TAM, individuals must meet a subgroup criteria within one of the following coverage groups. The coverage groups, along with the subgroups are in order of hierarchy.

a. Chronically Homeless - Is an individual:

i. Who is living or residing in a place not meant for human habitation, in a safe haven, or an emergency shelter for at least 12 months, or on at least 4 separate occasions totaling at least 12 months in the last three years, and has a:

· diagnosable substance use disorder,

· serious mental illness,

· developmental disability,

· post-traumatic stress disorder,

· cognitive impairments resulting from a brain injury, or

· chronic illness or disability.

ii. Who is living or residing in a place not meant for human habitation, a safe haven, or in an emergency shelter for a total of six months within a 12-month period, and has a:

· diagnosable substance use disorder,

· serious mental health disorder,

· diagnosable developmental disability, or

· post-traumatic stress disorder.

iii. Who is a victim of domestic violence who is living or residing in a place not meant for human habitation, a safe haven or in an emergency shelter; or

iv. Currently living in supportive housing who has previously met the definition of chronically homeless as specified in paragraphs a i, a ii, or a iii, above.

b. Justice Involved – Is an individual who is in need of substance use or mental health treatment and:

i. has complied with and substantially completed a substance use disorder treatment program while incarcerated in jail or prison;

ii. on probation or parole with a serious mental illness or substance use disorder.

iii. is currently involved in a drug or mental health court;

iv. is court ordered to receive substance abuse or mental health treatment through a district or tribal court:

v. was discharged from the State Hospital and was admitted to the civil unit in connection with a criminal charge, or to the forensic unit due to a criminal offense, with which the individual was charged or convicted.

c. Individuals Needing Treatment – Is an individual who:

i. discharged from the State Hospital due to a civil commitment; or

ii. is currently receiving General Assistance (GA) from DWS and has been diagnosed with a substance use or a serious mental health disorder.

2. The criteria for meeting a coverage group will be determined at application or review. See 731-8 for specific requirements.

a. Individuals who meet eligibility criteria for multiple subgroups should be placed in the highest subgroup for which they are eligible. (See section B.1 for hierarchy order)

b. Individuals approved for a subgroup that does not require a new referral at review (see 731-8) should remain on the same subgroup at review, unless moving up the hierarchy to another subgroup that also doesn’t require a new referral at the next review.

3. TAM Referral Forms

a. At application, the coverage groups and sub-groups described in B.1.a., b. and c. will be verified with one of the TAM forms:

· Chronically Homeless 42A,

· Justice Involved 43A or

· Individuals Needing Treatment 44A.

An approved agency (Table XVII) will complete the appropriate from and submit it to DWS.

b. At review, the coverage groups and sub-groups described in B.1.a., b. and c. can be verified with one of the TAM forms or may be verified by performing a collateral contact with the approved agency from Table XVII who last submitted a signed TAM referral form on behalf of the member.

c. Incarceration Dates: For the following Justice Involved sub-groups, the form must include the incarceration dates and be submitted no later than 60 days after the release date:

· Complied with and substantially completed a substance use disorder treatment program while incarcerated in jail or prison and

· Discharged from the State Hospital and was admitted to the civil unit in connection with a criminal charge, or to the forensic unit due to a criminal offense, with which the individual was charged or convicted.

d. Verify the substance use or mental health disorder for the GA sub-group with a Form 1, 20, 20M or 45A.

· Only request the 45A if the disorder cannot be verified using other means in the case record.

· Do not request a Form 1, 20 or 20M if it is not already in the case file.

· For verifying a substance use or mental health disorder, the Form 1, 20 and 20M are only valid for 12 months from the date completed.

· The Form 45A must be completed by a licensed practitioner (Such as a doctor, therapist or nurse practitioner) or an approved agency (Table XVII).

e. The TAM referral form (42A, 43A, 44A or 45A) can be submitted as part of the application, review or as a change report. Follow the time frames stipulated in sections 703-2 (application), 705-1 (retroactive coverage), 721-1 (reviews) and change report (815) when looking at eligibility for a different program. (See b. above).

C. Non-Financial Requirements

In addition to the non-financial requirements in Section 200, individuals must also meet the following criteria:

1. An individual must be at least 19 and not yet age 65.

2. Cannot have a dependent child under the age of 19.

3. Individuals are not eligible for TAM if they qualify for other programs without a premium or spenddown. Some of the programs are:

· Parent and Caretaker Relative,

· Pregnant Woman,

· Medicaid Cancer Program,

· Former Foster Care.

· Disabled Medicaid

4. An individual is not eligible for TAM if they are eligible for or receiving Medicare.

5. If an individual is eligible for TAM, do not put them on:

· Adult Expansion program (Individuals may receive Adult Expansion until they become eligible for TAM),

· Medically Needy programs; or

· Refugee Medical Assistance.

6. An individual may qualify for TAM in the retroactive period, if the individual met the eligibility criteria for one of the TAM coverage groups during the retroactive period.

D. Financial Requirements

1. No asset test.

2. Income must be at or below the income limit for the program (Table VII).

E. Open Enrollment Period

1. The Department of Health and Human Services may limit the number of individuals covered under the program. Open enrollment may be limited to individuals within a coverage group and/or a subgroup within a coverage group (346 Resource).

2. The following are exceptions to the open enrollment period:

a. The review process is completed in the three-month period immediately following the month the review closed for incomplete review (721-1).

b. The individual was previously on TAM and is moving from another Medicaid program with no breaks in coverage between all the programs.

F. Certification Period

1. See 715 regarding the length of the certification period

2. Medicaid coverage will end prior to the 12-month certification period if the individual:

a. Turns age 65;

b. Begins receiving Medicare;

c. Moves out of state;

d. Fails to apply for Medicare Part B, if eligible;

e. Becomes institutionalized (See 604 for suspending coverage); or

f. Is determined eligible for another Medicaid program, with the exception of Adult Expansion, Refugee or Medically Needy.