721-1 Ex Parte Reviews (Reviews Not Requiring Member Participation)

Effective Date: March 1, 2024

The agency must attempt an ex parte review on all programs. This is a redetermination of eligibility based on current, reliable information without requiring member participation. The ex parte review must be attempted on all programs before member participation is required.

A. Completing the Ex Parte Review

Use current electronic data sources and reliable case information to complete the review without contacting the member.

a. Determine if the electronic information can be used to update the case file (731-1).

b. Electronic income not previously reported may be verified if there is enough information to complete a best estimate. (435-2, 731-1, and 1004)

c. Update TPL evidence if there is no change. If there is a change, complete the ex parte review and request verification to update the TPL, treat the change separately as a change report (815).

Any form of verification (731) may be used as long as it does not involve requesting information from the member, such as, electronic verification or collateral contact.
Do not update income or assets that cannot be verified by an electronic data source if they are not questionable or have already been verified through another source within the last 6 months.

This includes assets such as bank accounts, IRA or trust accounts.
This includes income such as alimony, cash contributions, or child support payments.

Signatures are not required for ex parte renewals.
Once the agency has enough information to complete the ex parte review, update eligibility and send a notice of decision.
1. Members must not lose coverage due to an ex parte review. If the result of the ex parte review would be a loss of coverage, stop the ex parte process and require a member participation review (721-2 or 1008-2 for UPP).
2. If the review results in eligibility for the same program, begin the new certification period following the current certification period.
3. Members can be moved between programs during an ex parte review.

Members cannot be moved to Medically Needy, MWI, UPP or TAM programs, nor can they be moved to the NH or LTC Waiver programs if they have a contribution to the cost of care. Member participation is required (721-2 or 1008-2 for UPP).
Moving from Medicaid to CHIP is only allowed at the end of the current certification period.
Complete the ex parte when the member is not eligible for the current program and is eligible for another medical program that is not prohibited by (c)(i).
- - Example – Do not request a TAM referral form if the member is not eligible for TAM, such as being over the TAM limit, complete the ex parte and approve another program.

Apply the following effective dates if there is a change in the spenddown, MWI premium, or the cost of care:
- If the change is an increase, the effective date of the change is the first day of the month after the month in which proper notice was sent.
- If the change is a decrease, the effective date of the change is the first day of the month the review is completed.
- The change may not coincide with the start of the new certification period.
For the Adult Expansion program without premium reimbursement, access to employer sponsored health insurance must be verified with each review. Collateral contact should be attempted by phone. For this program, follow the steps below if collateral contact was unsuccessful:

Complete the ex parte determination, update eligibility, and set a new certification period.
Send a notice requesting verification of the status of the member’s employer sponsored health insurance (i.e. confirming current cost of premium if already enrolled, now eligible to enroll, no longer a qualified plan, etc.).
Give the member at least 10 days from the date of the notice to return verification. If verification is not returned by the due date, close with proper notice. If verification is received, make any necessary updates and redetermine eligibility.

To continue the Adult Expansion program with ESI, the premium must be verified through collateral contact if the premium was not verified within the last 6 months. For this program, if collateral contact was required but unsuccessful member participation is required.
For the UPP program, if the premium can be verified through collateral contact or the premium was verified within the last 6 months and:
1. 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 the 10-day notice.

The member remains eligible for UPP and there is no change to the premium reimbursement amount, begin a new 12-month certification period the month after the current certification period ends.
The member remains eligible for UPP but there is a change to the premium reimbursement amount, follow sections 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 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.
- Exceptions to the 12-month certification period are in section 1008 still apply.

If an ex parte review has not been attempted and a member participation review (online, telephonic or pre-populated) has been completed, attempt to complete the ex parte review before using the completed review.
- If the ex parte is completed, use the completed review as a change report form and follow policy 815.
- If the ex parte cannot be completed, use the completed review form as a member participation review (721-2 or 1008-2 for UPP).
If the member responds to the ex parte review notice of decision or submits a member participation review, treat the response as a change report (815 or 1009 for UPP).
If unable to complete the ex parte review, document any action taken and the reason(s) it could not be completed in the case record and require member participation (721-2 or 1008-2 for UPP).

B. When Member Participation May be Required

Below are examples when member participation may be required (721-2) if you cannot gather the information without member participation (i.e. by electronic verification, collateral contact, etc):

1. 1. If a member loses eligibility for all medical programs, do not close the current program.
  2. If a data match finds income that has not been reported and there is not enough information to complete a best estimate of income, such as not having a full quarter of wages.
  3. If income cannot be verified electronically and is subject to change on a regular basis. Some examples are:
    - Yearly COLA for retirement income,
    - self-employment, or
    - rental income.
  4. If the household has zero income or has expenses and not enough income to cover the expenses, and it has not been verified since the last medical renewal or application.
  5. If the change would move the member to a medically needy, MWI, UPP, or NH or LTC Waiver programs with a contribution to the cost of care.
  6. If a data match finds a new vehicle that could place the individual over the asset limit.
  7. If an individual's assets are close to the asset limit.
  8. If the review was set up to verify assets at the end of an exclusion period, such as for an SSA lump sum.
  9. If a member is receiving a premium reimbursement for UPP or Adult Expansion with Employer Sponsored Insurance and the premium cannot be verified without member participation.
  10. If a new referral form is required at review for the Targeted Adult Medicaid program.
  11. If the household has a trust that needs a trust accounting review.
  12. If an individual receives Long-Term Care and it is the first review following a protected period for the member to transfer excess assets to their spouse (573-6).
  13. If the member loses Medicaid eligibility and becomes eligible for UPP.