All Medicaid Programs |
Obsolete Policy |
The eligibility agency may use various methods to conduct a review. However, an UPP review requires member participation. An ex parte review is not allowed.
Completion of the Review
Send the member a review form that is pre-populated with the most current information from electronic records. The review form is provided to the household early enough to allow the recipient time to provide the updated information to complete the review during the review month.
The review form will explain what the member is required to do to complete the review process and the due date for responding.
If the member responds by the due date, or sometime during the review month, request needed verification from the member.
Use all available resources to determine continued eligibility before requesting the member to provide documentation.
If verification from the member is needed, send a written request and give the member at least 10 days to provide the verification.
If the member does not return all requested verification by the due date, eligibility ends at the end of the month for which the eligibility agency can give 10-day notice.
The member has three months after the effective closure date to complete the review without having to re-apply. (See B.)
If the agency cannot give 10-day notice before deciding eligibility for a new certification period, extend benefits to the following month. This is called the “due process month”. (See section 811 for exceptions to 10-day advanced notice.)
Benefits cannot be extended during the eligibility review for an UPP eligible child who turns age 19 or an UPP eligible adult who turns age 65 in the review month.
If the member provides all the requested verification by the verification due date, the eligibility agency proceeds with the eligibility decision. Determine if any individual would be eligible for Medicaid before re-determining UPP eligibility. (See section 1004 to determine countable income)
Consider only relevant factors of eligibility to complete the review for each household member.
Do not end or adversely change eligibility until the end of the month for which the eligibility agency can give a 10-day notice.
The agency continues eligibility into the following month (the “due process month”) if needed while it makes a decision.
If the member provides all requested verification after the due date and before the end of the review month, proceed with the eligibility decision.
The agency continues eligibility into the following month (the “due process month”), if needed, while it makes a decision.
Do not end or adversely change eligibility until the end of the month for which the eligibility agency can give 10-day notice.
If eligibility is continued into the “due process month”, the member must provide verification by the verification due date.
If the member provides verification by the due date, complete the review and send the notice of the eligibility decision.
Waive the ‘already has insurance’ rule.
If the member remains UPP eligible, begin the new certification period the first day of the next month.
Do not end or adversely change eligibility until the end of the month for which the eligibility agency can give 10-day notice.
If the action is in the member's favor make the change for the month immediately following the change report month. This may require a change to be made in the due process month.
Example: The member has a June review for July benefits. They provide their review on June 25th and report a decrease in income. The worker issues a due process month for July. The member returns all requested verifications on July 7th, prior to the verification due date. The member is eligible for an increase in the UPP premium. Because the change was reported in June and verified timely, the worker makes the income change effective for July.
If the member fails to provide verification by the due date, close the case and send notice.
If an overpayment investigation determines individuals were not eligible in the review month and a due process month was established, the referral must include the due process month.
Member fails to complete review process
If the case closes because the member fails to complete the review, eligibility ends at the end of the month in which proper notice can be sent. The member has three months from the date of case closure to complete the review without submitting a new application. (If eligibility is extended to the month after the review month, the three month period begins after the second month.)
The benefit effective date is the first day of the month in which the recipient contacts the agency.
There is no retroactive benefit.
No interview or application form is required.
Eligibility does not continue while the agency makes a decision.
Application processing time applies.
If the member fails to respond within three months after the case closes for failure to complete the review, require a new application.