Premium Billing Workaround (WA674)

Due to changes in federal legislation, CHIP beneficiaries cannot be discontinued during a continuous eligibility period due to failure to pay premiums. The following steps outline the procedure for when EDBC is run prior to a review being completed.

This work around will be overriding the entire EDBC for CHIP beneficiaries who are still within their CE period. For children currently in a penalty period, an override does not need to be completed. These CHIP beneficiaries will complete their penalty period. This override will be needed when EDBC attempts to close a CHIP recipient for premium delinquency during a CE period beginning 01/01/2024. Override would not be needed for child/children that are newly added to the case or new to CHIP coverage on the case.

NOTE: Workers will need to pay close attention when a case has multiple children on CHIP coverage with different CE periods. Override will only be completed for the child/children who are up for review.

1. From the Medical EDBC Summary page, click the Override Program Configuration button.

2. On the Program Configuration page, update the following fields:

   1. EDBC Override Reason: Administrative Decision.

   2. Program status: If the program block has a discontinued or denied status, please update this field to Active. Otherwise, leave blank.

   3. Update Reporting Type: Semi-Annual Reporting. This field is required.

3. Click the Override button next to consumer who needs information updated.

4. On the Program Configuration Override Detail page in the User Override section update the following fields:

   1. Role: MEM

   2. Status: Active

   3. QHP Screened: NO

   4. Claiming Code: Federal

   5. Status: leave blank

   6. Role Reason: leave blank

   7. Adult Child Code: leave blank

5. Click the Save and Return button.

6. On the Program Configuration Override List page, click the Save and Return button.

7. On the Medical EDBC Summary page, click Override Medical Summary at the bottom of the page.

8. The Medical EDBC Override List page displays. Select Override next to the failed CHIP build for all beneficiaries.

9. Overriding a budget:

   1. From the Medicaid EDBC Override Detail page, in the User Override complete the following fields:

      1. Test: leave as is.

      2. Test Result: Change to Pass.

      3. FPL%: leave as is.

      4. Premium: leave as is.

      5. Start date: First day of the month EDBC is being run for.

      6. End Date: Last day of the month EDBC is being run for.

      7. CHIP Start Date: First day of the month EDBC is being run.

      8. Premium start date: Month EDBC is being run.

   2. In the Individual Budget Unit (IBU) section complete the following fields:

      1. For the CHIP beneficiary being overridden:

         1. Person: Name of individual

         2. Role: MEM

         3. Aid Code: Select the appropriate Aid Code:

            1. Title XXI – Deemed Newborns

            2. Title XXI – Newborn (for $0 premium)

            3. Title XXI – Newborn Cost Share (for a $20, $30, or $50 premium)

            4. Title XXI – Age 1-5 (for $0 premium)

            5. Title XXI – Age 1-5 Cost Share (for a $20, $30, or $50 premium)

            6. Title XXI – Age 6-18 (for $0 premium)

            7. Title XXI – Age 6-18 Cost Share (for a $20, $30, or $50 premium)

   3. Click the Save and Return button to go back to the Medicaid EDBC Override List page.

10. The Continuous Eligibility Override Detail page displays.

    1. Enter the CE End Month using the <MM/YYYY> format or the calendar icon. The CE End Month should be the same as the original CE End Month.

    2. Select the Adjustment Reason: New Policy/ Regulation Change

    3. Repeat step 10 for all applicants requiring a CE End Month adjustment.

11. The Medical EDBC Override List page displays again. Now the budget has been created. Check the box next to the budget and click Save and Return.

12. The EDBC Medical Summary page now displays showing the newly created budget for our consumer. Click the Accept button.

13. The EDBC List page displays. Click the Save and Continue button.

14. Once EDBC is saved and accepted, confirm that the CE Period displays on the Medical Person History page.

    1. If it doesn’t display correctly, create a KEES Help Desk ticket.

15. Create a Journal using the following approved Journal language:

    1. WA674 was used to continue CHIP coverage for <consumer names>.

16. Create a manual Form if needed, using the Standard Copy and paste spreadsheet as an overridden EDBC will never create a NOA.

Workers will need to manually add penalty periods when a new application is received and/or when a review is due for a CHIP eligible child who is premium delinquent. Home > KEES User Manual Introduction > Family Medical > CHIP Medical > Manually Updating a Penalty Period