Unwinding Q&A Chart

Questions

Flagged or other held open cases

Non-flagged cases

1

When will a program get reviewed after the continuous eligibility requirement ends?

Flagged programs will be assigned a new review month.  Continue following the continuous eligibility requirement until the review is complete.

Non-flagged programs will follow their regular review period.

2

During the unwinding of the continuous eligibility, can Medicaid eligibility end before the scheduled review?

In most cases, no.  There are a few exceptions when the agency may end Medicaid with proper notice:  

• If a member dies.
• Moves out of the state permanently.
• Asks the agency to end their Medicaid coverage.

·       If the case was approved in error.

·       A child who has been adopted.

Follow policy 811

3

Can a Medicaid member be moved to CHIP before the end of their scheduled review period?

Flagged Medicaid members cannot be moved to CHIP before the end of their forced eligibility review date.

The only exceptions are:

• If the member requests to be moved to CHIP.
• If Medicaid was approved in error.

Follow policy 721

4

While completing a SNAP/Fin/CC/Medical review or application can the Medicaid review also be completed?

Overall, flagged programs should not be reviewed outside their assigned date.

However, you may complete the review at a SNAP/Fin/CC/Medical review or application if you have all the necessary information.  

The only exception is Medicaid members moving to CHIP, see question#3.

Follow policy 721 and 815.

5

What is the review process after the continuous eligibility ends?

Follow policy 721 for the assigned review month.

Follow policy 721.

6

When is an ex parte review required?

It is always required to attempt the ex parte review.

If the ex parte was not attempted before the review sent, then an ex parte must be attempted.

If the ex parte was not attempted and the review is returned, then an ex parte must be attempted.

It is always required to attempt the ex parte

If the ex parte was not attempted before the review sent, then an ex parte must be attempted.

If the ex parte was not attempted and the review is returned, then an ex parte must be attempted.

7

Should I complete an ex-parte review when the member has zero income and no electronic income data received?

Yes, but only if the member’s income has been verified after March 1, 2019. 

Yes, but only if the member’s income was verified after March 1, 2019.

8

How should the eligibility agency handle changes in circumstances that impact ongoing eligibility?

Overall, flagged programs should not be reviewed outside their assigned date. 

The ex parte review may be attempted:

If still eligible for a Medicaid program, complete the review and approve the program they are eligible for.

When attempting an ex parte review, members cannot be moved to a Medically Needy, MWI, UPP, CHIP, or the NH or LTC Waiver programs if they have a contribution to the cost of care. Member participation is required.

If the ex parte cannot be completed:

The program will continue to be forced until the assigned review.

If the program must change according to the COVID-19 Questions and Answers Unwinding Resource, move the individual to the appropriate program. With the exception of Pregnant Woman, change the review due date to match the assigned review month.

Follow Policy 815 on when to make the change effective.

Act on the change according to policy 815.

9

What if someone’s time-limited Medicaid ends during the unwinding period? For example, a child turns 19, 12-month TR would end, etc?

Redetermine eligibility for another program.

If the member is only eligible for a program with a premium, spenddown, cost of care, UPP, CHIP, or if unable to redetermine eligibility for another program, follow the established COVID-19 Questions and Answers Resource and move the individual to the appropriate program to remain eligible. With the exception of Pregnant Woman, change the review due date to match the assigned review month.

The agency must redetermine eligibility for other programs and provide proper notice. Follow policy 721-4.

10

When is a signature page required for a child aging off of a Medical program?

Complete the ex parte without the signature page. The signature page is required post eligibility. Follow policy 827

If unable to redetermine eligibility for another program, follow the established COVID-19 Questions and Answers Resource and move the individual to the appropriate program to remain eligible. With the exception of Pregnant Woman, change the review due date to match the assigned review month.

Complete the redetermination without the signature page, but it is required post eligibility. Follow policy 827

If unable to complete the redetermination because verifications are needed, also request the signature page.

11

When will the Emergency Medicaid programs be closed?

The emergency program may be closed after the review is completed and the emergency need is over.

Most emergency cases will be reviewed in the final month of the unwinding.

Note: If the member has end-stage renal failure these emergency programs will continue to remain open.

After the member's emergency need is over. Follow policy 205-6

Note: If the member has end-stage renal failure these emergency programs will continue to remain open.

12

When does a member need to pay a spenddown or an MWI premium?

A spenddown or MWI premium payment will not be required to be met until a review is completed if they have met it once already during the PHE coverage requirement. Do not close until the review is completed.

However, members may continue to meet their spenddown or MWI premium payment.

After the review is complete, close if the member does not meet the spenddown or MWI premium for two consecutive months.

(Note:  This is for cases that are NOT flagged and have never met the spenddown or MWI premium or are newly eligible)

Follow normal processing.

13

When does a Waiver member need to pay a contribution to the cost of care?

A contribution to the cost of care is required to be met for the member to have eligibility. Do not close until the review is completed. Members may pay waiver cost-of-care contributions retroactively for any months during the continuous eligibility enrollment period and unwinding period until the review is completed.

After the review is complete, close the program if the member does not meet the Waiver contribution to cost of care for two consecutive months.

A contribution to the cost of care is required to be met for the member to have eligibility.

Members may pay waiver cost-of-care contributions retroactively for any months during the continuous eligibility enrollment period and unwinding period until the review is completed.

Close the program if the member does not meet the Waiver contribution to cost of care for two consecutive months.

14

Can an overpayment be assessed for an ineligible month?  

No overpayments can be assessed for any period during the continuous eligibility requirement period, from March 1, 2020 through the end of the month in which their unwinding review was completed.

If there is suspected fraud, the agency may refer the case for criminal investigation.

If the agency suspects member abuse, refer the case for investigation. If the agency determines the member received eligibility due to member abuse, close the case. The decision does not affect eligibility for the previous months during the continuous eligibility requirement period.

Same as flagged.

15

Should UPP be considered for Adult Expansion members receiving an ESI reimbursement, who are no longer eligible for Adult Expansion after a review is completed?

If after the review they are no longer eligible for Adult Expansion with ESI, Determine eligibility for UPP. Follow policy 1003-2

Yes, follow policy 1003-2

16

Are Adult Expansion members required to enroll in ESI?

After the case is reviewed, give the member another opportunity to enroll in their ESI, sending a new Must Enroll in ESI notice.

If the member does not enroll, allow eREP to sanction the Adult Expansion recipient according to policy 348-3.4.

Yes, if the member does not enroll, allow eREP to sanction the Adult Expansion recipient according to policy 348-3.4.

17

What happens with an application that is approved for retro months during the continuous eligibility requirement?

When members qualify during any retro months during the continuous eligibility requirement, the eligibility will be forced through the end of the continuous eligibility requirement.

Same as flagged cases.

18

Do members get another opportunity to provide verification of citizenship or immigration status?

When completing the review, allow the member 95 days to provide citizenship or immigration status verification.

If citizenship or immigration status is not provided, then close the program after the due date.

Refer to the Guideline for Citizenship and ID for Medicaid, CHIP and UPP Programs Resource.

Follow policy 205.

19

Should a member’s program close if they are Medicare Part B eligible, but did not enroll during the continuous eligibility requirement or the coverage unwinding period?

No, send the Apply for Medicare Part B notice at the assigned review month or when the member turns 65. Keep the program open after the review is complete, and allow the member 90 days to apply for Medicare Part B, then the program can be closed for failure to apply for other benefits. (Policy 223-2)

Refer to the Apply for Medicare Part B Procedure.

Follow policy 223-2.

20

What action should be taken for returned mail during the unwinding period?

Do not close any flagged program as a result of returned mail.

Additionally, any returned mail received during unwinding that relates to a member’s review requires attempting to contact the member using at least  two additional modalities (email, phone, text, other). Each contact method and attempt must be documented in the case record.

Below are how to handle each type of returned mail:

1.    Returned Mail with insufficient address.

a.    Update address, if possible, and resend. This meets the requirement.

b.    If unable to correct the address:

                                      i.    Must use two additional contact methods (Email, Phone, Text, or Other).

                                     ii.    Fewer contact methods are allowed if we don’t have other contact information.

2.    Returned mail with No Forwarding Address.

a.    Must use two additional contact methods (Email, Phone, Text, or Other).

b.    Fewer contacts methods are allowed if we don’t have other contact information.

3.    Returned mail with Forwarding address.

a.    Must use two additional contact methods.

                                      i.    Re-sending the mail to an updated address counts as first modality.

                                     ii.    Attempt to contact the member through at least one additional method (Email, Phone, Text, or Other).

                                    iii.    Fewer contact methods are allowed if we don’t have other contact information.

Follow policy 811-4

21

When should Medicaid recipients be sanctioned for non-cooperation with medical support enforcement?

Continue coverage until the assigned review month.

When the review is completed, allow an additional 60 days to cooperate with the medical support enforcement requirement.

If they do not cooperate or claim good cause by the due date, sanction as appropriate.

Refer to policy 227-2

Follow policy 227-2

22

When should Medicaid be sanctioned for TPL cooperation?

Continue coverage until the assigned review month.

When the review is completed, allow an additional 10 days to cooperate.

If they do not cooperate or claim good cause by the due date, sanction as appropriate allowing advanced notice.

Refer to policy 225-5

Follow policy 225-5

23

Should a flagged PCR month count towards the 3 out of 6 month requirement for Transitional Medicaid?

Yes, treat the flagged PCR months toward the 3 out of 6 month requirement. Transitional would begin in the month in which proper notice can be given.

Yes, follow policy 343-2 and  follow the Family 12-Month Transitional and Family 4-Month Extended Medicaid procedure.

24

Should a member continue receiving benefits pending the outcome of a fair hearing?

Yes, continue benefits until the outcome of the fair hearing. Overpayments shall not be collected on the continued benefits.

Continue benefits until the outcome of the fair hearing. Overpayments shall not be collected on the continued benefits.

25

Will someone who remains eligible for Adult Expansion during the unwinding period be eligible for an ESI reimbursement prior to their review month?

Yes, if one of the following situations apply:

1.   If the member is on Adult Expansion and their income increases and puts them over the Adult Expansion income limit, but is still within the UPP income level, continue Adult Expansion with ESI as long as they have access to and are enrolled in health insurance that meets QHP. Subsequent income changes during the unwinding period will not stop the ESI payment.  

2.  If a member is on Adult Expansion with ESI and they have an income change that puts them over the UPP income limit, continue coverage on Adult Expansion with the ESI payments.

No, if one of the following situations apply:

1.      The member is on Adult Expansion and lost access to ESI, the ESI ends, or the health insurance no longer meets QHP criteria.

2.      The member is on Adult Expansion without ESI. They report a change in both income and access to ESI. However, the new income is over the UPP income level.  We will not give the option of ESI.  We will continue them on Adult Expansion during the unwinding period with no ESI option.   

3.       The member is on Adult Expansion without ESI and no longer meeting the requirement to cover their children with Minimum Essential Coverage or has an ORS sanction due to the medical support enforcement requirement, we will not offer an ESI reimbursement. 

Follow policy 348-3

26

When should the Adult Expansion program close for members who do not meet the Minimum Essential Coverage (MEC) requirement?

Not until the review is complete. Follow policy 348 and the Gathering Information for Minimum Essential Coverage (MEC) procedure.

Follow policy 348 and the Gathering Information for Minimum Essential Coverage (MEC) procedure.

27

When a client is unable to sign an application (paper/online/in person), what options do they have?

There are two ways. See policy 703-1.

1.    Complete a telephone application with a telephonic signature.

Same as flagged.

28

Can I accept a ‘signature’ from an assistor or other community partner for applications or reviews?

Starting on October 1, 2023, assistors and other community partners (assistor) may be able to sign applications and reviews on the applicant or recipients (individual) behalf with verbal consent from the individual.  The assistor will complete the form 114UNWINDING documenting the verbal consent.

The assistor will be acting as an authorized representative with limited scope to sign the application or review on behalf of the individual only during the Medicaid unwinding period.

This signature and the name of the agency they work for must be noted in the case record.

Same as flagged