Medicaid Policy                                                                 

721 Eligibility Review

Effective Date: January 1, 2025

Previous Policy

 

An eligibility review is the process of gathering and verifying all factors of eligibility to determine if a member remains eligible for any medical program.

1. Reviews are required for members on any Medicaid program.

1. 1. Members who are open on a MAGI program must be reviewed once every 12 months, and no more frequently than once every 12 months.

• • • A woman receiving Medicaid coverage while pregnant or in her postpartum period on any program, will not need to complete a review until the end of her postpartum period.

1. 2. Members who are open on a Non-MAGI program must be reviewed at least every 12 months.

• • • Exception for Medicare Cost-Sharing programs:

• • • • The review period for Medicare cost-sharing programs is 12 months.

• • • • Leave the Medicare cost-sharing program open if the member does not complete their review for another program that is required before the Medicare cost-sharing review.

1. 3. The agency must use all reliable information available, such as electronic data sources. Reliable information may also include:

• • • Information received within the last 6 months from other benefit programs or reliable sources for the determination as long as no discrepancies are identified (e.g., information provided in the Supplemental Nutrition Assistance Program (SNAP) recertification (731)).

• • • Available information in the members’ account that is recent and reliable.

• • • Information from the initial determination at application or the member’s last renewal if it relates to circumstances that generally are not subject to change (e.g., citizenship or satisfactory immigration status).

2. The agency must begin the review process early enough that a redetermination can be made before the end of the current certification period. A member’s eligibility review is started when the agency begins the ex parte redetermination process and is completed when the member is determined to either remain eligible for a benefit, or has been found ineligible for all programs.

3. The agency must attempt an ex parte redetermination of benefits on all programs. An ex parte redetermination is based on current, reliable information without requiring any information from the member (721-1). The ex parte redetermination must be attempted before member participation is allowed.

4. The agency may not terminate coverage, until the member is either found ineligible for any program or until the member fails to complete the review process timely (827).

5. See section 811-1 if coverage needs to be extended via Due Process