No 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 it is determined an ex parte review is unsuccessful. When reviewing the UPP program see section 1008-2 for reviews requiring member participation.
2. 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.
3. Once the member responds to the review, use current electronic verification and case information to decide if the member needs to provide any other verification to complete the review.
a. If verification is needed, send a written request and give the member at least 10 days to provide the verification.
b. Once the agency has enough information to complete the review, update eligibility and send a notice of decision.
c. If the agency cannot make an eligibility decision before 10-day notice or the agency makes an adverse decision but does not have time to send 10-day notice, extend benefits into the due process month.
d. Do not approve a due process month if the member does not attempt to complete the review before the end of the review month.
4. If eligibility is extended into the due process month, the member must provide requested verification by the due date.
a. If the member provides verification by the due date, update eligibility and send a notice of decision.
b. If the member provides verification by the due date but the agency cannot complete the review and notify the member of an adverse action before 10-day notice, approve a second due process month. Complete the review and send a notice of decision.
i. 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.
ii. 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 the month in which proper notice is sent.
iii. If not eligible, the effective date of the change is the end of the month in which proper notice is sent.
c. If the member fails to provide all requested verification by the due date, close the case effective the end of the due process month and send a notice of decision.
d. If the member provides verification after the due date but before the end of the due process month, the date the verification is received is a new application date. If eligible, benefits are effective the first day of the month after the due process month.
5. If additional verification is requested, give the member at least ten days to provide the verification. Approve a second due process month, if needed.
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.
a. If eligibility is extended into a due process month, the three months begin the month after the due process month.
b. 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.
c. Determine retroactive eligibility back to the closure date.
d. If the member does not contact the agency to complete the review during the three months after closure, the member must reapply.