All Medicaid Programs |
Obsolete Policy |
Reviews Not Requiring Client Participation (ex parte)
Ex parte reviews will be conducted for most MAGI and non-MAGI based programs. Do not conduct an ex parte review in the following situations, as they require client participation in the review process:
A non-MAGI program with earned income, unless the income does not affect eligibility, such as an SSI recipient (485-1) or waiver programs with less than $65 earned income (435-2);
The household has self-employment or rental income;
An UPP, Adult Expansion with Employer Sponsored Insurance premium reimbursement or Targeted Adult Medicaid program;
The household has a special needs or pooled trust; or
An individual receives Long-Term Care and it is the first review following a protected period for the client to transfer excess assets to their spouse (573-6).
Use current electronic data sources and case information to complete the review.
Update changes in assets and income using current electronic data sources.
If income verification is incomplete or there is not at least one full quarter of wages to complete a good best estimate, an ex parte review cannot be completed.
The only exception is if the income was verified within the past 6 months, such as using an employer statement or check stubs.
A best estimate of income can be completed on income not previously reported if there is enough information to complete a good best estimate (refer overpayments if applicable).
If TPL information is needed, complete the ex parte review and request needed verification and treat as a change report (815).
Do not change or remove assets or income that cannot be verified by an electronic data source, if the asset or income has already been verified by the agency through another source and the asset or income is not questionable.
For assets, this includes such things as bank accounts, IRA or trust accounts.
For income, this includes such things as alimony, cash contributions, child support or pension payments.
Refer to ex parte review procedure regarding reviews for indigent aliens.
If medical assistance can be renewed for the same program using electronic data sources and case information, update eligibility, set a new certification period and send a notice of decision. There are a few exceptions when an ex parte review can be completed when moving to a different program:
Moving from PCR to transitional;
Moving from one cost-sharing program to another; or
Moving from an ABD or Waiver program with no spenddown to the same program type with a spenddown. Income must be unearned and verified.
The certification period begins the month after the review month. (See 721 on updating certification periods for other medical programs.)
If there is a change in the spenddown or the cost of care, the following apply:
If the change is a decrease, the effective date of the change is the first day of the month after the review is completed.
If the change is an increase, the effective date of the change is the first day of the month after the month in which proper notice is sent.
The change may not coincide with the start of the new certification period.
If the client responds to the ex parte review notice of decision, treat the response as a change report (815).
If there are questionable items that need to be verified, do not complete an ex parte review. Use the regular review process. Client participation is required when, but is not limited to:
A data match finds income that has not been reported and there is not enough information to complete a good best estimate of income, such as not having a full quarter of wages;
Income cannot be verified electronically and is subject to change on a regular basis (Example: Yearly COLA for retirement income);
A data match finds a new vehicle that could place the individual over the asset limit;
An individual's assets are close to the asset limit; or
The review was set up to verify assets at the end of an exclusion period, such as for an SSA lump sum.
REVIEWS REQUIRING CLIENT PARTICIPATION
The agency will send a pre-populated review form to the client the month before the review month. Recipients may complete a review electronically, in person, over the phone or in paper form. Client participation in the review process is required for all programs for which an ex parte review cannot be completed.
Once the client responds to the review, use current electronic data and case information to decide if the client needs to provide any other verification to complete the review.
If verification is needed, send a written request and give the client at least 10 days to provide the verification.
Once the agency has enough information to complete the review, update eligibility and send a notice of decision.
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.
If not eligible, the effective date of the change is the end of the month in which proper notice is sent.
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.
Do not approve a due process month if the client does not attempt to complete the review before the end of the review month.
If eligibility is extended into the due process month, the client must provide requested verification by the due date.
If the client provides verification by the due date, update eligibility and send a notice of decision.
If the client provides verification by the due date but the agency cannot complete the review and notify the client of an adverse action before 10-day notice, approve a second due process month. Complete the review and send a notice of decision.
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.
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.
If not eligible, the effective date of the change is the end of the month in which proper notice is sent.
If the client 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.
If the client 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.
If additional verification is requested, give the client at least ten days to provide the verification. Approve a second due process month, if needed.
If a program closes for incomplete review, including not providing requested verification, allow the client three months to respond without requiring a new application.
If eligibility is extended into a due process month, the three months begin the month after the due process month.
If the client 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.
Once the client has contacted the agency within the three month period, application policy and time frames apply, even if that time extends past the 3 months (703).
Determine retroactive eligibility back to the closure date.
If the client does not contact the agency to complete the review during the three months after closure, the client must reapply.