A redetermination of eligibility for continued Medicaid
benefits must be completed every 12 months.
007.01
RENEWAL OF ELIGIBILITY FOR
MODIFIED ADJUSTED GROSS INCOME (MAGI) PROGRAMS. A renewal of
modified adjusted gross income (MAGI)-based eligibility shall be completed on
the basis of information available to the Department without requiring
information from the individual. Information will only be required from the
individual when not available through other sources. If information is not
available to complete a renewal, a prepopulated renewal form shall be sent by
the Department to the applicant or authorized representative. The completed
renewal form and necessary verifications shall be returned within 30 days of
the date the renewal form was sent.
007.02
RENEWAL OF ELIGIBILITY FOR
NON-MODIFIED ADJUSTED GROSS INCOME (non-MAGI) PROGRAMS. A
prepopulated renewal form shall be required every 12 months for non-modified
adjusted gross income (non-MAGI) based eligibility renewals.
007.03
RENEWAL FOR SUPPLEMENTAL
SECURITY INCOME (SSI) RECIPIENTS. A renewal form is not required
at the time of renewal for clients who are receiving Supplemental Security
Income (SSI).
007.03(A)
RENEWAL
DURING NON-PAY SUPPLEMENTAL SECURITY INCOME (SSI) STATUS. A
renewal is not required for periodic non-pay status due to an extra pay period
in a month.
007.03(B)
SUPPLEMENTAL SECURITY INCOME (SSI) CLIENTS ELIGIBLE UNDER
1619(b). Supplemental Security Income (SSI) clients who are
determined eligible for Medicaid by the Social Security Administration (SSA)
under the provisions of 1619(b) are not required to complete a renewal form,
and resources do not need to be verified.
007.04
INCOME REVIEW FOR AGED,
BLIND, AND DISABLED (ABD) CLIENTS. For eligibility purposes, a
review of income must be completed every 12 months. An income review is
completed by the Social Security Administration (SSA) for Supplemental Security
Income (SSI) clients, including those placed in 1619(b) status.
007.05
DISABILITY REVIEW FOR
AGED, BLIND, AND DISABLED (ABD) CLIENTS. For clients whose
disability status is approved by the State Review Team (SRT), a periodic review
of the disability determination is required. Reviews of the disability
determination are conducted consistent with the relevant portions of the
Supplemental Security Income program and 20 Code of Federal Regulations (CFR)
Part 416 Subpart I.
007.05(A)
REQUIRED DISABILITY REVIEWS. A review of a
beneficiary's disability status will occur in the following circumstances:
(i) The previous determination period has
ended;
(ii) The beneficiary was
determined disabled as a child, and is now turning age 18;
(iii) The beneficiary begins, or returns, to
work, and the income earned is greater than the Substantial Gainful Activity
(SGA) amount published by the Social Security Administration (SSA);
(iv) The Department receives credible
evidence or reports that the beneficiary is no longer disabled; or
(v) The beneficiary reports that the
disability has ended.
007.05(B)
REQUIRED
DOCUMENTATION. The State Review Team (SRT) requires
contemporaneous documentation of a beneficiary's health condition in order to
determine whether the beneficiary meets the disability criteria. The medical
documentation must be dated no more than 12 months prior to the date for which
a disability determination is requested. The medical documentation must include
an examination by a physician or another appropriate provider for the condition
or conditions related to the disability determination dated no more than 12
months prior to the date for which a disability determination is requested. A
failure to provide all necessary documentation will result in a denial of
disability status.
007.05(C)
DURATION OF DISABILITY DETERMINATION. The length of
time during which a beneficiary is considered to be disabled is dependent on
the beneficiary's medical condition. A shorter time period is assigned if the
medical evidence indicates that the beneficiary's medical condition may improve
in order to ensure that the beneficiary continues to meet the disability
criteria. The beneficiary's condition, and length of the disability review
period, is re-determined at each review. The review schedule is determined as
follows:
(i) A disability review will be
conducted every 12 months when the disability may reasonably be expected to
improve;
(ii) A disability review
will be conducted every three years if the disability is not permanent, but the
possibility for medical improvement cannot be accurately predicted; or
(iii) A disability review will be
conducted every five years if it is unlikely that the medical condition will
improve.
