Medicaid Policy
Medicaid Policy
The eligibility agency may use various methods to conduct a review. Member participation is required once it’s been determined an ex parte review cannot be completed (721-1). Member participation can begin as soon as it is determined an ex parte review is unsuccessful.
A. Completion of the Review
1. Send the member a review form that is pre-populated with the most current information from electronic records. The review form is provided to the household early enough to allow the recipient time to provide the updated information to complete the review during the review month.
· The member may complete their review online, by telephone or by using the pre-populated review form sent to the member the month before the review month. Signatures are required on reviews that require member participation and follow the same rules as application signatures found in section 703-1.
2. The review form will explain what the member is required to do to complete the review process and the due date for responding.
3. If the member responds by the due date, or sometime during the review month, use current electronic verification and case information to decide if the member needs to provide any other verification to complete the review.
a. Use all available resources to determine continued eligibility before requesting the member to provide documentation.
· If verification is needed, send a written request and give the member at least 10 days to provide the verification.
b. Once the agency has all the requested verification, the eligibility agency proceeds with the eligibility decision. Determine if any individual would be eligible for Medicaid before re-determining UPP eligibility. Only relevant factors of eligibility will be considered to complete the review for each household member. (See section 1004 to determine countable income)
· If the member becomes eligible for another medical program without a spenddown, or MWI premium the change will take effect the month after the UPP certification period ends unless the member requests. If the member requests the move to Medicaid to take effect prior to UPP certification end date, the change will take effect the month the request is received regardless of 10-day notice.
· If the member remains eligible for UPP and there is no change to the premium reimbursement amount begin a new 12-month certification period. Begin the new certification period the month after the current certification period ends.
· If the member remains eligible for UPP but there is a change to the premium reimbursement amount, follow section 1007-1 or 1007-2 to determine the effective date for the change in premium. Begin the new certification period the month after the current certification period ends.
· If the member is no longer eligible for UPP, the effective date of the change is the end of the month in which proper notice is sent but not before the last date of the current certification period.
o Exceptions in the 12-month certification period found in section 1008 still apply.
c. If the agency cannot make an eligibility decision before 10-day notice or the agency makes an adverse decision but does not have time to send 10-day notice, extend benefits into the due process month. (See section 811 for exceptions to 10-day advanced notice.)
· Benefits cannot be extended during the eligibility review for an UPP eligible child who turns 19 or an UPP eligible adult who turns age 65 in the review month (210).
d. Do not approve a due process month if the member does not attempt to complete the review before the end of the review month.
4. If the member does not return all requested verification by the due date, eligibility ends at the end of the month for which the eligibility agency can give 10-day notice but not before the last date of the current certification period.
· The member has three months after the effective closure date to complete the review without having to re-apply. (See B.)
5. If eligibility is continued into the “due process month”, the member must provide verification by the verification due date.
a. If the member provides verification by the due date, complete the review and send the notice of the eligibility decision.
· Waive the ‘already has insurance’ rule.
· If the member remains UPP eligible, begin the new certification period the first day of the next month.
b. Do not end or adversely change eligibility until the end of the month for which the eligibility agency can give 10-day notice or before the certification period end date.
c. If the action is in the member’s favor make the change for the month immediately following the change report month. This may require a change to be made in the due process month.
a. Example: The member has a June review for July benefits. They provide their review on June 25th and report a decrease in income. The worker issues a due process month for July. The member returns all requested verifications on July 7th, prior to the verification due date. The member is eligible for an increase in the UPP premium. Because the change was reported in June and verified timely, the worker makes the income change effective for July.
d. If the member fails to provide verification by the due date, close the case and send notice.
6. If an overpayment investigation determines individuals were not eligible in the review month and a due process month was established, the referral must include the due process month.
B. Member fails to complete review process
1. If the case closes because the member fails to complete the review, eligibility ends at the end of the month in which proper notice can be sent. The member has three months from the date of case closure to complete the review without submitting a new application. (If eligibility is extended to the month after the review month, the three month period begins after the second month.)
a. The benefit effective date is the first day of the month in which the recipient contacts the agency.
· There is no retroactive benefit.
· No interview or application form is required.
b. Eligibility does not continue while the agency makes a decision.
c. Application processing time applies.
2. If the member fails to respond within three months after the case closes for failure to complete the review, require a new application.