An eligibility review is the process of gathering and verifying all factors of eligibility to determine if a member remains eligible.
1. Reviews are required for all Medicaid programs.
a. MAGI programs must be reviewed once every 12 months, and no more frequently than once every 12 months.
b. Non-MAGI programs 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 when the member does not complete a review that is required more often than 12 months for another program.
c. Changes reported between review periods that affect eligibility may begin a new 12-month renewal period, if the following conditions are met:
· Only if the agency has enough information available to renew eligibility with respect to all eligibility criteria,
· The agency must limit any requests for additional information from the individual to information relating to such change in circumstance.
2. The eligibility agency must begin the review process early enough that a redetermination can be made before the end of the current certification period.
3. The agency must attempt a redetermination of benefits on all programs based on current, reliable information without requiring any information from the member (ex parte review)(721-1).
a. Any form of verification may be used as long as it does not involve asking the member for verification (731).
b. Members may move between medical programs during the ex parte review.
c. If available information is insufficient to determine continued eligibility, member participation in the review is required (721-2 or 1008-2 for UPP).
d. If an ex parte review has not been attempted and a review (online, telephonic or pre-populated) has been completed, the ex parte must be attempted before using the completed review. If the ex parte can be completed, use the completed review as a change report form. If the ex parte cannot be completed, use the completed review form as a member participation review (721-2 or 1008-2 for UPP).
4. If unable to complete the ex parte review, member participation is required (721-2 or 1008-2 for UPP).
5. See 715 for length of certification period or 1008 for UPP.
6. See 435 for budgeting of income or 1004 for UPP.
7. See 815 for changes during the certification period or 1009 for UPP.