Mississippi Administrative Code
Title 23 - Division of Medicaid
Part 101 - Coverage Groups and Processing Applications and Reviews Redetermination Processes
Chapter 12 - The Redetermination or Renewal Process
Rule 23-101-12.6 - Exparte Reviews
Universal Citation: MS Code of Rules 23-101-12.6
Current through September 24, 2024
A. Any individual or beneficiary under review who is losing eligibility in one (1) category of eligibility is entitled to have eligibility reviewed and evaluated under all available coverage groups.
B. The term "exparte review" is defined as to review information available to the Division of Medicaid to make a determination of eligibility in another coverage group without requiring the individual or beneficiary to come into the regional office or file a separate application.
1. For
an exparte determination to be made, the Division of Medicaid must be in the
process of making a decision on a current application, review or reported
change. If the Division of Medicaid is denying or closing the case for failure
to return information or failure to complete the interview process, an exparte
determination is not applicable.
2.
The decision of whether the individual or beneficiary is eligible under a
different coverage group must be based on information contained in the case
record which may include:
a) Income,
household or personal information in the physical record which indicates the
ineligible adult or child has potential eligibility in another coverage group
and/or
b) Information received
through electronic matches with other state or federal agencies such as a
disability onset date or prior receipt of benefits based on
disability.
3. When
potential eligibility under another coverage group is indicated, but the
Division of Medicaid does not have sufficient information to make an
eligibility determination, the individual or beneficiary must be allowed a
reasonable opportunity to provide the necessary information.
4. If the individual or beneficiary is
subsequently determined to be eligible in the new category, the approval is
coordinated with termination in the current program to ensure there is no lapse
or duplication in coverage.
a) If requested
information is not provided or if the information clearly shows that the
individual or beneficiary is not eligible under another category, eligibility
in the current program will be terminated with advance notice.
b) During the advance notice period, the
individual or beneficiary is allowed time to provide all requested information
to determine eligibility in the new program, provide information which alters
the decision to terminate benefits in the current program or request a Fair
Hearing with continued benefits.
5. If the individual or beneficiary
subsequently provides all of the information needed to assess eligibility in
the new program within ninety (90) days from the effective date of termination
for modified adjusted gross income (MAGI) or aged, blind and disabled (ABD)
closurest, the case is handled in accordance with the redetermination
reinstatement procedures. A new application is not required.
C. Social Security Income (SSI) terminations due to excess income and/or resources are treated as a type of exparte review.
1. A review form is
issued to the individual terminated from SSI.
2. If a signed renewal form is returned by
the individual prior to the SSI closure date, eligibility will be determined
using available information, if possible.
3. If return of a signed renewal form is not
possible, written requests for information will be provided to attempt
placement in an appropriate Medicaid-only category of eligibility.
42 U.S.C. § 1396a; 42 C.F.R. § 435.916; Miss. Code Ann. § 43-13-121.
Disclaimer: These regulations may not be the most recent version. Mississippi may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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