Reporting Requirements
A Medicaid recipient or his/her representative is responsible to report changes that may affect eligibility. The member must report within 10 days of the date of the change. Section 107-4 describes changes that must be reported.
If the 10th day is a non-business day, the due date for reporting a change is the first business day following the 10th day.
Changes may be received from a source other than the recipient.
Follow the 10*10*10 rule.
The recipient has 10 calendar days to report a change from the date the change occurs;
The agency must take action on the reported change within 10 calendar days of the report; and
The agency must provide a 10-day advance notice of a negative action.
If the change is not reported timely, determine if an overpayment occurred and refer if appropriate (825).
Taking Actions on Changes
Workers must decide what action to take when a change is reported. The worker must take the appropriate action within 10 days of the report date.
Do not take action on income or household changes for individuals eligible for the Pregnant Woman program unless she is eligible for a better program.
If a woman is eligible and receiving Medicaid when she reports a pregnancy, add her pregnancy to case evidence and determine if she qualifies for a better program. If she qualifies for a better program, she may choose to continue coverage on her current program or move to the better program. She must not lose eligibility through the pregnancy and postpartum period (349).
Do not close the medical programs when the member fails to provide verification for changes that cause an increase in benefits (e.g. lower spenddown or MWI premium) or do not make the member ineligible. Do not increase benefits until the verification is received.
If verification is needed, send a written request to the member and give the member at least 10 days to provide the verification (731).
Once the agency has enough information, update eligibility and determine the effective date of the change per Section C below and send a notice of decision.
If a change causes a recipient to lose eligibility, the agency will determine eligibility for other medical programs (827). Individual information will be sent to the FFM if no longer eligible.
Do not set a new 12-month certification period unless all factors of eligibility have been verified.
See 815-1 for a change in address.
See 815-4 for changes in household composition.
See 815-5 for changes in income.
Effective Date of a Change
If a change is adding a new individual to a Medicaid program, application policy and time frames apply (703).
If a change makes a household member eligible for a better program, decreases a spenddown, MWI premium or the cost of care, the effective date is:
The month of report, if verified timely; or
The month verified, if not verified timely.
If a change causes a household member to lose eligibility, increases a spenddown, MWI premium or cost of care, the effective date of the change is the first day of the month after proper notice is sent.