Medicaid Policy                                                                 

815 Changes

Effective Date: January 1, 2025

Previous Policy

 

A. Reporting Requirements

1. A Medicaid recipient or his/her representative is responsible to report changes that may affect eligibility. The member must report within 10 days of the date of the change. Section 107-4 describes changes that must be reported.

1. 1. If the 10th day is a non-business day, the due date for reporting a change is the first business day following the 10th day.

1. 2. Changes may be received from a source other than the recipient.

2. Follow the 10*10*10 rule.

1. 1. The recipient has 10 calendar days to report a change from the date the change occurs;

1. 2. The agency must take action on the reported change within 10 calendar days of the report; and

1. 3. The agency must provide a 10-day advance notice of a negative action.

3. If the change is not reported timely, determine if an overpayment occurred and refer if appropriate (825).

B. Taking Actions on Changes

1. Workers must decide what action to take when a change is reported.  The worker must take the appropriate action within 10 days of the report date.

1. 1. Reported income or household changes for individuals eligible for the Pregnant Woman program may only affect their coverage if they are eligible for a better program.

1. 2. A pregnant woman who is receiving ABD should not be removed from that program during the certification period unless they are no longer disabled. If no longer disabled, move the member to the appropriate program for the remainder of the certification period.

1. 3. If a woman is eligible and receiving Medicaid when she reports a pregnancy, add her pregnancy to case evidence and determine if she qualifies for a better program.  If she qualifies for a better program, move her to the better program.  She must not lose eligibility through the pregnancy and postpartum period (349).

1. 4. A child receiving Medicaid cannot lose coverage during their certification period due to a reported change, unless it is an exception listed in policy section 715. However, if the reported change would make the child eligible for a better program, the child may be moved to the better Medicaid program for the remainder of the certification period.

• • • A child that is receiving ABD should not be removed from that program during the certification period unless they are no longer disabled. If no longer disabled, they can be moved to the appropriate Medicaid program for the remainder of their certification period.

• • • Upon discharge from the NICU, a child that is receiving Nursing home coverage should be moved to ABD if they are disabled. If not disabled, move the child to the appropriate Medicaid program for the remainder of the certification period.

2. Do not close medical programs when the member fails to provide verification for changes that would cause an increase in benefits (e.g. lower spenddown or MWI premium) or do not make the member ineligible.  Do not increase benefits until the verification is received.

1. 1. If verification is needed, send a written request to the member and give the member at least 10 days to provide the verification (731).

1. 2. Once the agency has enough information, update eligibility and determine the effective date of the change per Section C below and send a notice of decision.

3. If a change causes a recipient to lose eligibility for their current program, the agency will determine eligibility for other medical programs prior to terminating their coverage (827).

1. In order to make an eligibility determination for a new program, factors of eligibility that are required under the new program that were not addressed under their current program will need to be addressed. See 731 for acceptable methods of verification.

2. If additional verification from the member is needed to determine eligibility under a new program, send a written request to the member and give the member at least 10 days to provide the verification (731).

3. The agency must limit any requests for additional information from the member to those previously unaddressed factors.

4. A due process month will need to be issued if ongoing eligibility is not determined with sufficient time to give proper notice. See 811-1

Example: A child is open on Child medical and is then found to be disabled. Eligibility for ABD should be addressed. Address assets if they have not been addressed. The child may be moved to ABD for the remainder of their certification period if eligible.

4. Do not set a new 12-month certification period unless all factors of eligibility have been verified.

5. See 343-5 for changes reported during the 12 month Transitional period.

6. See 815-1 for a change in address.

7. See 815-4 for changes in household composition.

8. See 815-5 for changes in income.

9. Individual information will be sent to the FFM when a member is no longer eligible for or no longer receiving coverage through any groups covered by the state.

C. Effective Date of a Change

1. If a change is adding a new individual to a Medicaid program, application policy and time frames apply (703).

2. If a change makes a household member eligible for a better program, decreases a spenddown, MWI premium or the cost of care, the effective date is:

1. 1. The month of report, if verified timely; or

1. 2. The month verified, if not verified timely.

3. If a change causes a household member to lose eligibility, increases a spenddown, MWI premium or cost of care, the effective date of the change is the first day of the month after proper notice is sent.