Medicaid Policy                                                                 

721-2 Reviews Requiring Member Participation

Effective Date: January 1, 2025

Previous Policy

 

 

1. Members must participate in the Medicaid review process when it’s been determined an ex parte review cannot be completed (721-1). Participation can begin as soon as a pre-populated review form is available for the member. When reviewing the UPP program see section 1008-2 for reviews requiring member participation.

2. Member participation involves providing the member with a pre-populated review form which must include the most recent, reliable, and relevant information used to determine eligibility for the member.

• • • • The form may only require members to provide information needed for renewal.

• • • • The agency must not require members to complete an in-person interview as part of the renewal process.

3. The member may complete their review online, by telephone, or by using a 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.

4. Once the member responds to the review, use current electronic data sources and case information to decide if the member needs to provide any other verification to complete the review.

1. 1. If verification is needed, send a written request and give the member at least 10 days to provide the verification.

1. 1. 1. Refer to 811-1 when the agency cannot make an eligibility decision before 10-day notice of the review month.

• • • • If the member fails to provide all requested verification, close the program effective the end of the month in which proper notice is given and send a notice of decision.

1. 2. Once the agency has enough information to complete the review, update eligibility and send a notice of decision.

1. 1. 1. If there is a decrease in the spenddown, cost of care or the MWI premium, the change will be effective:

• • • • the month of report, if verified timely; or

• • • • the month verified, if not verified timely.

1. 1. 2. If there is an increase in the spenddown, cost of care or MWI premium, the effective date of the change is the first day of the month after proper notice is given.

4. 1. 3. If not eligible, the effective date of the change is the end of the month in which proper notice is given.
5. If additional verification is requested, give the member at least ten days to provide the verification. If the verification is due after 10-day notice, extend coverage by approving a due process month (811-1).

6. If a program closes for incomplete review, including not providing requested verification, allow the member three months to respond without requiring a new application.

1. 1. If eligibility is extended into a due process month, the three months begin the month after any due process month.

1. 2. If the member contacts the agency, or submits all previously requested verification to complete the review during the three-month period, the date of contact or submittal of requested verification is the application date.

1. 3. Determine retroactive eligibility back to the closure date.

1. 1. 1. Retroactive coverage does not need to be determined for any month(s) in which the member states they do not need the coverage.

1. 4. If the member does not contact the agency to complete the review during the three months after closure, the member must reapply.