All Medicaid Programs |
Obsolete Policy |
Deadline for determining eligibility
The eligibility worker must make an eligibility decision within 30 days of the date of the application. In the case of an application received through the FFM, make the decision within 30 days from the date the individual’s electronic account was received. Determine eligibility for MAGI programs first before looking at non-MAGI or medically needy programs. If the applicant is claiming to be disabled, make an eligibility decision within 90. If the 30th or 90th day is a non-business day, you have until the following business day to make a decision.
Applicants may request more time to provide verifications before the end of the application period. (See Family Medicaid Sec. 503-4 for policy about when to accept client statement as verification of assets.)
If you cannot make an eligibility decision by the deadline, document the cause of the delay.
Do not deny the application because the disability decision is taking more than 90 days if you do not have any other reason for deciding the person is not eligible.
Wait for the Disability Review Office's decision before taking action.
If you receive a decision from Social Security about the person's disability status before you receive one from the Disability Review Office, notify the Disability Review Office and take the appropriate case action based on SSA's decision. (See policy in Sec. 303 to decide what action to take based on SSA's decision.)
If unverified eligibility factors do not affect the eligibility of the entire household, approve the application for those household members determined eligible. For example, the client has not given proof of alien status for one child. Do not approve the application if unverified eligibility factors affect the whole household. (For example, the wages of a working parent are unverified.)
Take steps to obtain the unverified eligibility factors.
If the applicant does not respond to the requests by the deadline, or by the end of the processing time, whichever is longer, deny the application.
If the applicant asks for more time to provide verifications before the end of the application processing time, OR the agency asks for more information, give the client at least 10 more days to provide the verifications, extending the application time as needed to give the client time to return verifications.
When verifications are received that show the applicant is ineligible, deny the case.
You do not have to wait until the end of the 30- or 90-day period to send the denial notice when you have proof the client is not eligible.
If a disability review has been requested, and other verifications show the person is ineligible, tell the Disability Review Office you are denying the application.
Do not deny the application before the end of the 30- or 90-day processing period if verifications have not been received. Instead, wait until the end of the application processing time before denying for lack of verifications.
If the applicant returns verifications within 30 days after an application has been denied, use the date the verifications are received as a new application date.
The client does not have to complete a new application form; however, document the new application date.
Determine the available retroactive months based on the new application date. (See Sec. 107-2 and 705)
Documentation of decision
Document the eligibility decision.
If the application is denied, note the date and the reason for the denial.
If the application is approved, indicate the date and the medical assistance programs approved for the various household members. If some members are approved and others denied, clearly narrate this.
Notification of approval or denial
When the application is approved or denied, notify the applicant in writing of the approval or denial. If different decisions are made for different household members, address each decision in the notice or notices.
If the client must pay for coverage (spenddown, MWI premium, PCN enrollment fee, or cost of care for long-term services), explain this in the notice and how and where payment can be made. The notice must give the policy section that covers the reason for a payment.
If the application is denied, state the reason for the action and give the policy citation for the denial reason.
Tell the client where to call if the client has questions or concerns.
Transferring an electronic account to the FFM
1. The electronic client information will be transferred to the FFM when an application is denied.