COVID-19 Unwinding Questions and Answers Resource

Effective Date: May 1, 2023

Resource

On April 1, 2023 the continuous eligibility requirement ended allowing member’s medical benefits to close as soon as April 30, 2023. All medical programs will need to be reviewed by March 2024. (Or at least have begun the renewal; however, all reviews must be completed by May 2024.

During this unwinding period all programs that were flagged will be assigned a review month. Use this resource to determine which program to continue forcing during the unwinding period until the assigned review month.

If the member was not flagged during the continuous eligibility requirement period, follow normal processing guidelines.

In all cases where the member dies, loses residency, was approved due to agency error or requests to have their case closed, the eligibility should end.

Note - For situations not mentioned in this document, consult with a policy specialist from the Department of Health and Human Services for guidance.

Change Report Reference Guide for Flagged Cases
Reported Change	Action to take prior to assigned review date
A flagged member reports being pregnant	If all necessary information is available to complete a review, and the member is eligible for the current program, give her the pregnancy category. Update certification period according to policy 715 and remove the flag indicator. If she is not eligible for the current program, then approve Pregnant Woman following policy 349 and remove the flag indicator.
Member becomes eligible for Medicare and is currently on TAM or Adult Expansion.	If all necessary information is available to complete a review and the member meets all the criteria for the Aged or Disabled 100% FPL group, move them to that program and add QMB. Update the certification period according to policy 715 and remove the flag indicator. If all necessary information is not available to complete the review, or the member is not eligible for Aged or Disabled 100% FPL. force the Aged or Disabled 100% FPL group with QMB. Change the review due date to match the assigned review month. The flag indicator should remain on the case until the assigned review month.
Medical Review Board has determined the member to be Disabled while on a non-Aged Blind or Disabled program	If all necessary information is available to complete a review and the member meets all the criteria for the Aged or Disabled 100% FPL group, move them to that program. Update the certification period according to policy 715 and remove the flag indicator. If all necessary information is not available to complete the review, or the member is not eligible for Aged or Disabled 100% FPL continue to force eligibility for the medical program the member is receiving. Do not remove the flag indicator or change the assigned review month. With the exception of Pregnant Woman, change the review due date to match the assigned review month. The flag indicator should remain on the case until the assigned review month.
Member moved out of the household, but remains in Utah	If all necessary information is available and the member is eligible for the same medical program or a program higher in the hierarchy, complete the review. Create a new case, update the certification period, and remove the flag indicator. If all necessary information is not available to complete the review or the member is no longer eligible, create a new case for the member and continue to force eligibility for the same medical program. The new case should remain flagged, and the forced review month should be the same. With the exception of Pregnant Woman, change the review due date to match the assigned review month. The flag indicator should remain on the case until the assigned review. Create a new case for the spouse or child that left the home if the new address is known. If the address is unknown, continue coverage on the current case. Exception, when any domestic violence issues have been reported, create a new case using general delivery.
Any other change	If all necessary information is available to complete the review and the member is eligible for the same medical program or a program higher in the hierarchy, complete the review, and remove the flag indicator. If information is not available to complete an ex parte review, continue to force eligibility for the appropriate tier Medicaid program from the table below. With the exception of Pregnant Woman, change the review due date to match the assigned review month. The flag indicator should remain on the case until the assigned review.

Correction to Tier Forcing for Medicare Cost Sharing programs
Background	Between November 2020 and March 2023, DHHS transitioned certain members from receiving full Medicaid benefits to a Medicare cost sharing program. DHHS has revised their policy to allow these members to remain eligible for both full Medicaid benefits while also receiving their Medicare cost sharing program during this period (Carr vs Becerra Lawsuit).
Existing situation before correction	Actions Required
Medicare Cost Sharing is the only open program	o Check the Medical Benefit history to see if the member has received a Medicaid program without a spenddown or MWI premium since March, 2020. o If no, further action is not needed. o If yes, the following Medicaid programs must be reopened back to the month of closure: ABD 100%, ABD SSI, and PCR. o If any of these Medicaid programs are reopened The MCSP program must continue or be changed to QMB. o The Medicaid program and the QMB program will both need to be continued through their unwinding review month. Example: Sally has been receiving AEM since October 2018. In June, 2022, she turned 65 and began receiving Medicare Part A and Part B. On June 1, 2022 her Adult Expansion changed to QMB only with an unwinding review month of May 2023. o The Worker needs to approve ABD 100% and MCSP QMB back to June 1, 2022, and continue forcing coverage through the unwinding review month (May 2023).
A Spenddown or MWI program is open with Medicare Cost Sharing	o Check the Medical Benefit history to see if the member has received a Medicaid program without a spenddown or MWI premium since March, 2020. o If no, further action is not needed. o If yes, the following Medicaid programs must be reopened back to the month of closure: ABD 100%, ABD SSI, and PCR. o If any of these Medicaid programs are reopened The MCSP program must continue or be changed to QMB. o The Medicaid program and the QMB program will both need to be continued through their unwinding review month. Example: Bob was approved for ABD 100% and QMB starting July 1, 2021. On January 1, 2022 his programs were changed to ABD MN and SLMB. Bob never met the spenddown, so only the SLMB program remained open with review in August, 2023. o The worker needs to approve ABD 100% and QMB back to January 1, 2022, and continue forcing coverage through the unwinding review month of August, 2023.
Changes have occurred after the Continuous Eligibility Requirement for Flagged or other held open cases	Once a full review has been completed at the member’s scheduled review month, the member’s case can then transition to an appropriate spenddown/MWI and SLMB/QI program. Programs can close if members are no longer eligible for any other programs. Example: Larry is on ABD 100% and QMB in May 2023, and the member reports an increase of income that puts him over the 100% FPL on May 1, 2023. Larry’s unwinding review is in July, 2023. o The worker needs to keep ABD 100%, and QMB open through larry’s unwinding review month of July, 2023.
Changes have been made after the Continuous Eligibility Requirement for Non-flagged cases	Members can transition to having a spenddown or MWI premium, and being placed on spenddown, MWI, or SLMB /QI cases. Programs can close if the member is no longer eligible for any other programs. Example: Mary is receiving ABD 100% and QMB. In April, 2023, Mary reports an increase of income that puts her over the 100% FPL and under the 120% FPL April 1, 2023 with an August 2023 review. o The Worker needs to move Mary to SLMB and ABD Medically Needy with a spenddown required beginning May 1, 2023.

Tier 1 Programs
Program	Program to force until assigned review month
Adult Expansion	If the member has Medicare and not eligible for MCSP, then force Aged, or Disabled 100% FPL and QMB. Member can move between Adult Expansion with or without ESI depending on enrollment in a QHP, as long as they remain under the UPP income limit.
Aged, Blind or Disabled with no spenddown	Must remain on Aged or Disabled 100% FPL
Breast or Cervical Cancer (BCC)	If unable to force BCC can move to Aged or Disabled 100% FPL.
Child 6-18	Force Child 6-18 until the member turns 19 then force Adult Expansion.
Child 0-5	Force Child 0-5. When the member turns 6, force 6-18.
Child 1yr	When the member turns 1, force 0-5.
Lawfully Present Medicaid child	Force Child Medical. When member turns 19, force Adult Expansion emergency. Move to Tier 3.
Former Foster Care (age 26)	When the member turns 26, force Adult Expansion.
Foster Care	Force Child or Adult Expansion depending on age.
Foster Care Independent Living	Force Foster Care Independent Living. Member turns age 21 - force Adult Expansion.
Home and Community Based Waivers	Force Aged or Disabled 100% FPL.
Medicaid Work Incentive (MWI) without premium	Force MWI if they still have earnings. Force Aged or Disabled 100% FPL if they do not have earnings.
Medicare Cost Sharing Program only (MCSP) - QMB	Force QMB, SLMB or QI.
MCSP only - SLMB or QI	Force SLMB or QI.
MCSP and Aged, Blind or Disabled (ABD) with no spenddown (Combo cases)	If the member is ineligible for MCSP and ABD with no spenddown, then force Aged or Disabled 100% FPL and QMB.
Nursing Home	Force NH: sanctions do apply or Force applicable tier 1 category of coverage if they leave the nursing home. o For example: If the member is disabled force Disabled 100% FPL.
PCR	Force PCR until the assigned review month..
Pregnant Woman	Pregnant Woman can be forced until the assigned review month or member can be moved to Adult Expansion after the post partum period until the assigned review month.
Refugee (not Medicaid)	If not eligible for another program, close Refugee.
Sub Adopt	Force SA for the remainder of the coverage requirement period. DCFS will extend the adoption agreement end date on the program evidence for SA IV-E Medicaid. If the Sub-adopt agreement cannot be extended then force Child or Adult Expansion depending on age. (Coordinate with DCFS) FEAR evidence must be added for the SA Non IV-E Medicaid, to extend coverage beyond age 18.
TAM	Force TAM. If the member has Medicare force Aged or Disabled 100% FPL and QMB.
4 Month Extended	Force 4 month extended or Adult Expansion.
12 month TR	Force 12 month TR until the assigned review month.
Tier 2 Programs Note - Tier 1 clients may request to be moved to this tier.
Programs	Programs to force when not eligible for any Tier 1
Spenddown (Medically Needy (MN)) or MWI with premium	Force MN or MWI with premium.
Tier 3 Programs Note - Tier 1 and Tier 2 clients may request to be moved to this tier.
Programs	Programs to force when not eligible for any Tier 1 or Tier 2
COVID-19	Force COVID-19 until 05/11/2023. COVID-19 is no longer an eligible program after the PHE ends.
Emergency Programs	Force emergency
Presumptive Eligibility	Close at end of PE period, or Medicaid decision
Tuberculosis	Force TB
UPP	Keep open with $0 payment.
Other program
Program	Program movement
CHIP	May move from Plan B to Plan C. o If on Plan B, and not eligible for Plan C, then close CHIP allowing for proper notice. o If on Plan C, and not eligible for Plan C, then close CHIP allowing for proper notice. Cannot move from Medicaid to CHIP, but CHIP may move to Medicaid.

Tier quick reference guide
Tier 1	Tier 2	Tier 3
Adult Expansion	Medically Needy Programs	Covid 19
Aged, Blind, Disabled		Emergency Programs
Breast and Cervical Cancer		Presumptive Eligibility (HPE & BYB)
Child Programs		Tuberculosis
Former Foster Care		UPP
Foster Care
Foster Care Independent Living
HCB Waivers
Medicaid Work Incentive
Medicare Cost Sharing
Nursing Home
PCR
Pregnant Woman
Refugee
Sub-Adopt
TAM
4 month extended
12 month TR