Medicaid Policy
Medicaid Policy
Certification Period
The certification period is a 12-month continuous eligibility period with a few exceptions. Once an applicant is determined to be eligible, an individual remains eligible for the entire certification period.
The effective date of the certification period begins the first day of the application month when the applicant is determined eligible for UPP and the last month of the certification period is the review month (See 1007 and 1008-1).
Exceptions to the 12-Month Certification Period
An UPP member may lose eligibility before the end of the 12-month certification period in the following situations.
The member moves out of state or cannot be located.
The member enters a public institution or an institution for mental disease.
The member dies.
The member becomes eligible to enroll in Medicare.
The member turns 19. Eligibility ends the last day of the month the person turns age 19. (See section 1000-1)
The member becomes covered by the Veteran's Administration Health Care System.
The member gains access to VA benefits but does not follow through with the VA application process.
The member becomes eligible for another medical program without a spenddown, or MWI premium.
A child discontinues employer-sponsored health insurance or COBRA and enrolls in CHIP.
Create a new CHIP certification period.
An UPP member enrolls in, or there is a change in, an employer-sponsored insurance and the cost of coverage does not exceed 5% of the individual's countable income after any applicable 5% disregard is applied. (See section 1003-4 for how to determine cost of coverage)
An UPP member enrolls in a new employer-sponsored insurance and does not report it within 10 days from either the day the member signs up or the health insurance coverage begins, whichever is later.
A member's employer-sponsored insurance no longer meets the definition of an “UPP Qualified Health Plan”. (See Section 1003-1).
An UPP member enrolls in any other type of creditable health insurance coverage other than the employer-sponsored coverage or COBRA.
Health insurance coverage is not confirmed during the semiannual insurance review (See Section 1009-1).
A member is no longer covered in employer-sponsored or COBRA coverage.
When to Allow Due Process
When conducting a review, if you cannot give 10-day notice before determining eligibility, extend benefits to the following month. This month is not part of any certification period. (See Sections 811 and 1008-1)
When to Establish a New 12-Month Certification Period
The certification period for UPP must be re-determined at 12 months. A new 12-month certification period will be established when a member completes the review process at the end of a certification period and continued eligibility for UPP is established.
Create a new 12-month certification period when a member moves from CHIP or Medicaid to UPP. (See 1009-3 when adding an individual to an open UPP case.)
Transferring an Electronic Account to the FFM
The electronic member information will be transferred to the FFM when UPP is closed.