2016 LCM-01 - Transitioning MAGI Consumers from WMS to NY State of Health

To: Local District Commissioners

Subject: Transitioning MAGI Consumers from WMS to NY State of Health

Date: June 29, 2016

Division: Office of Health Insurance Programs

Attachments: Attachment I - MAGI Transition Schedule
Attachment II- T65 NY State of Health Invitation Notice Example
Attachment III - Reason Code W3H (MAGI Transition Medicaid to NY State of Health)
Attachment IV - Reason Code W4H (MAGI Individual Child under 18 and 9 months Transition to NYSOH)

The purpose of this Local Commissioners Memorandum (LCM) is to inform local departments of social services (LDSS) of the transition of individuals who are eligible under a Modified Adjusted Gross Income (MAGI) eligibility group from the Welfare Management System (WMS) to NY State of Health.

Since January 1, 2014, the eligibility of most individuals in a MAGI eligibility group has been determined through NY State of Health, with certain exceptions. Medicaid recipients who were enrolled prior to January 1, 2014, have remained on WMS and have been maintained by the local district until they could be transitioned to NY State of Health. T he transition to NY State of Health, which will occur in phases, is scheduled to begin in July 2016.


The transition of MAGI enrollees to NY State of Health will start with counties that use the Enrollment Center to process their renewals. Approximately one-half of the Enrollment Center population will start the transition in July 2016 and the remaining half will begin to transition in August 2016. It is anticipated that non-Enrollment Center counties will begin transitioning in March 2017, Nassau and Suffolk counties will transition in June 2017, and New York City (NYC) will transition following the transition of the upstate districts. Attachment I to this LCM contains an updated listing of counties and the corresponding expected transition begin month.

Individuals who are categorically MAGI eligible and receiving coverage through WMS will be transitioned to NY State of Health at their next scheduled renewal. Individuals will be selected for transition approximately 90 days prior to their eligibility end date. Once a specific county begins transitioning, the process will continue each month in that county until all of the MAGI enrollees are moved to NY State of Health. Once a district's MAGI population begins to transition to NY State of Health, districts are instructed to no longer extend the authorization period for cases with MAGI individuals. This should enable most MAGI renewals to transition to NY State of Health within a 12 month period, once the transition process starts. The only exceptions are for individuals who report a pregnancy during the authorization period and newborns. Districts should extend coverage for pregnant women to cover their 60-day post-partum period.

A subset of MAGI individuals will remain on WMS, including MAGI individuals receiving benefits under the Medicare Savings Program, individuals who are 64 years of age and not a parent or caretaker relative, those enrolled in the Family Planning Benefit Program (FPBP) without other household members on their case, and individuals who are in need of care and services that can only currently be provided through WMS. Individuals with FPBP coverage who are on a case with other MAGI family members, will be transitioned to NY State of Health. These individuals are likely on FPBP due to ineligibility for other assistance on WMS and NY State of Health will provide additional financial assistance options for health insurance for individuals with income up to 400% FPL

The MAGI transition, including Temporary Assistance (TA)/Medicaid discontinuances and TA/Medicaid denials, will utilize the same methodology as the Essential Plan transition outlined in 16 ADM-01, with a few differences outlined below.

The Department will apply the selection criteria to identify MAGI individuals who will transition to NY State of Health and create an electronic file of demographic information and satisfied verifications from WMS, such as immigration status, SSN and U.S. Citizenship. This data will not have to be verified again when individuals transition to NY State of Health. NY State of Health will receive this file and create a shell account for most individuals with the information from WMS to assist individuals in the transition.

WMS will generate a notice informing individuals that they are due for their annual renewal and the date on which their coverage on WMS will end. The notice will explain that they need to renew on NY State of Health to continue their coverage. Additionally, a letter will be sent by NY State of Health informing individuals how to access their NY State of Health account, refer to Attachment II for an example. It is the consumer's responsibility to complete his/her renewal in the date range specified in the notice. This can be done online using the invitation code, with a Navigator or Certified Application Counselor (CAC) or by contacting the NY State of Health customer service center. To further assist individuals in this transition, the Department will provide a list of individuals who are required to renew in NY State of Health to the recipients' current managed care plans in order for the plans to provide assistance.


A. Child-only Cases

Cases that only include active individuals who are less than 19 years of age will be handled differently than described above. WMS does not contain sufficient information on the parent(s) or caretaker(s) in order to establish an account on NY State of Health; therefore, these cases will not have shell accounts established on NY State of Health. The notice from WMS will inform the family they need to contact NY State of Health in order to avoid a gap in the child's coverage. This group will not receive instructions from NY State of Health. These individuals will need to create an account on NY State of Health or be added to a family member's previously established account.

B. Fair Hearing Rights

The notice sent from WMS will direct individuals to contact the NY State of Health customer service center to request an appeal. If an appeal is requested with aid continuing, the aid continuing will be granted by the LDSS on WMS. This will require coordination between NY State of Health and the LDSS. The Department (Bureau of Stakeholder Relations and Exchange Support) will generate a daily spreadsheet of cases that require aid continuing to be authorized on WMS. The spreadsheet will be provided to the local district Medicaid Director. The outcome of the appeal will also be communicated to the district via the spreadsheet.

The Department will be responsible for preparing for the appeal, and appeals will be heard by the NY State of Health Appeals Unit.


A. Medicaid Renewals

Current MAGI recipients will be transitioned to NY State of Health at the individual's regularly scheduled renewal, once the recipient's county of fiscal responsibility begins the transition process. Individuals will be selected based on a MAGI Individual Categorical Code (ICC) and MA coverage code. The selection process will identify cases containing MAGI and non-MAGI household members, delete the MAGI members, and transfer them to NY State of Health. Some MAGI individuals will be excluded from the transition. Excluded individuals include MAGI individuals who are age 64 as long as their Individual Categorical Code (ICC) is not 13 (FA/SN/LIF Dependent Relative) or 94 (Parents/Caretaker Relatives - 0 to less than or equal to 138% FPL (MAGI), individuals with a Medicare Savings Program (MSP) indicator code of P, L or U; those residing in nursing homes; individuals residing in certain Congregate Care settings; individuals in managed long term care; and individuals with suspended coverage (coverage code 26 or 25). Certain individuals were excluded from the Essential Plan transition due to the need for personal care services which are not available in the Essential Plan. These individuals will be selected for transition as part of the MAGI procedure, as personal care services can be accessed through Medicaid Managed Care.

Note: For the July 2016 transition only, cases that include a MAGI recipient with a MSP Indicator code of P, L or U, will have WMS coverage extended one month. The case will be pulled for recertification in August 2016 following the procedures described in this LCM.

Client Notice System (CNS) reason codes and notices have been created to inform the identified individuals of the requirement to renew through NY State of Health. For upstate districts, new Reason Code W3H (MAGI Transition Medicaid to NY State of Health) has been created to inform those identified of the renewal process (see Attachment III). NYC specific reason codes will be released prior to the NYC transition. Identified individuals will not be part of a district's regular renewal process nor will they be on the upstate WINR 4133 report. A new monthly report, WINR 4150, will be generated for upstate districts to identify cases impacted by this process. For mixed household cases (MAGI recipients and non-MAGI recipients), the district will continue to be responsible for the renewal of the non-MAGI household members and MAGI members otherwise excluded from the transition process, and these individuals will continue to appear on the district's WINR 4133 report. Such individuals will receive a renewal that must be returned to the local district for processing. After the transition begins in July and August 2016, renewal notices will no longer point consumers to the Enrollment Center for processing for those counties that were participating with the Enrollment Center.

B. Child-only Cases

Child-only cases will be selected based on MAGI criteria, the age of the recipient and the absence of MAGI adults in the household. New Reason Code W4H (MAGI Individual Child under 18 years 9 months Transition to NYSOH) has been created to inform child only cases of the renewal process (see Attachment IV).

C. Processing Changes and Openings

Districts are instructed to take action on reported changes to MAGI cases. Once a district begins transitioning MAGI cases, if a reported change results in a change in eligibility, the district is not to extend the authorization period. When adding a MAGI individual to a case, WMS will display edit 1943- IDENTIFIED MAGI INDIVIDUAL, TRANSACTION NOT ALLOWED. This edit may be overridden and coverage authorized only until the current case authorization end date. Pregnant women must have coverage extended to cover the 60-day post-partum period.

Districts are reminded of the continuous coverage provisions outlined in GIS 15 MA/22. Income or household changes that would render a MAGI individual ineligible for coverage should be noted in the case record but coverage is to continue to the end of the authorization period

When a case must be opened on WMS for a MAGI individual in order for the individual to receive care, services or benefits that can only be accessed through WMS, WMS will display edit 1944- IDENTIFIED MAGI INDIVIDUAL, OPENING NOT ALLOWED. This edit may be overridden.

Note: Individuals who report a change to the district after the individual's case has been pulled for transition should be advised to update their account on NY State of Health or to contact the NY State of Health customer service center.

D. Temporary Assistance Discontinuances

In NYC, the downstate separate determination process will remain unchanged. Individuals will receive a Medicaid extension on WMS as appropriate. The recertification process will evaluate individuals and, if appropriate, direct them to NY State of Health for their recertification.

E. Temporary Assistance Acceptances

Applicants who are determined eligible for Medicaid based on a combined TA and Medicaid application will not be transitioned to NY State of Health. These recipients will remain on WMS and receive Medicaid through WMS on their TA case.

F. Temporary Assistance Denials

Pursuant to current procedures (13 OHIP/ADM-04), when an individual applies at the district for both TA and Medicaid on the combined application, a separate Medicaid eligibility determination must be completed if the individual is denied TA. If the applicant is categorically MAGI, he/she must be referred to NY State of Health for an eligibility determination

When reviewing an application for Medicaid under the separate determination process for an applicant who is categorically MAGI, upstate districts must forward the application packet and supporting documentation to NY State of Health. CNS Reason Code DD2 will provide the applicant with proper notification.

New York City applicants denied/rejected for TA who are categorically MAGI will have their applications and supporting documentation transferred via a secure file transfer to NY State of Health.

Any questions should be directed to your local district Medicaid liaison at (518) 474-8887 for Upstate counties, and in NYC, (212) 417-4500.

Sincerely, ___________________________________
Jason A. Helgerson
Medicaid Director