Current through Bulletin 2024-06, March 15, 2024
(1) The
eligibility period begins on the effective date of eligibility as defined in
Section
R414-306-4,
which may be after the first day of a month, subject to the following
requirements.
(a) If a recipient must pay one
of the following fees to receive Medicaid, the eligibility agency shall
determine eligibility and notify the recipient of the amount owed for coverage.
The eligibility agency shall grant eligibility when it receives the required
payment, or in the case of a spenddown or cost-of-care contribution for
waivers, when the recipient sends proof of incurred medical expenses equal to
the payment. The fees a recipient may owe include:
(i) a spenddown of excess income for
medically needy Medicaid coverage;
(ii) a Medicaid Work Incentive (MWI) premium;
or
(iii) a cost-of-care
contribution for home and community-based waiver services.
(b) A required spenddown, MWI
premium, or cost-of-care contribution is due each month for a recipient to
receive Medicaid coverage.
(c) The
recipient must make the payment or provide proof of medical expenses within 30
calendar days from the mailing date of the application approval notice, which
states how much the recipient owes.
(d) For ongoing months of eligibility, the
recipient has until the close of business on the tenth day of the month after
the benefit month to meet the spenddown or the cost-of-care contribution for
waiver services, or to pay the MWI premium. If the tenth day of the month is a
non-business day, the recipient has until the close of business on the first
business day after the tenth. Eligibility begins on the first day of the
benefit month once the recipient meets the required payment. If the recipient
does not meet the required payment by the due date, the recipient may reapply
for retroactive benefits if that month is within the retroactive period of the
new application date.
(e) A
recipient who lives in a long-term care facility and owes a cost-of-care
contribution to the medical facility must pay the medical facility directly.
The recipient may use unpaid past medical bills, or current incurred medical
bills other than the charges from the medical facility, to meet some or all of
the cost-of-care contribution subject to the limitations in Section
R414-304-9.
An unpaid cost-of-care contribution is not allowed as a medical bill to reduce
the amount that the recipient owes the facility.
(f) Even when the eligibility agency does not
close a medical assistance case, no eligibility exists in a month for which the
recipient fails to meet a required spenddown, MWI premium, or cost-of-care
contribution for home and community-based waiver services.
(g) The eligibility agency shall continue
eligibility for a resident of a nursing home even when an eligible resident
fails to pay the nursing home the cost-of-care contribution. The resident,
however, must continue to meet all other eligibility requirements.
(2) The eligibility period ends
on:
(a) the last day of the month in which
the eligibility agency determines that the recipient is no longer eligible for
medical assistance and sends proper closure notice;
(b) the last day of the month in which the
eligibility agency sends proper closure notice when the recipient fails to
provide required information or verification to the eligibility agency by the
due date;
(c) the last day of the
month in which the recipient asks the eligibility agency to discontinue
eligibility, or if benefits have been issued for the following month, the end
of that month;
(d) for
time-limited programs, the last day of the month in which the time limit ends;
(e) for the pregnant woman
program, the last day of the month which is at least 60 days after the date the
pregnancy ends, except that for pregnant woman coverage for emergency services
only, eligibility ends on the last day of the month in which the pregnancy
ends; or
(f) the date the
individual dies.
(3) A
presumptive eligibility period begins on the day the qualified entity
determines an individual to be presumptively eligible. The presumptive
eligibility period shall end on the earlier of:
(a) the day the eligibility agency makes an
eligibility decision for medical assistance based on the individual's
application when that application is filed in accordance with the requirements
of Sections 1920 and 1920A of the Social Security Act; or
(b) in the case of an individual who does not
file an application in accordance with the requirements of Sections 1920 and
1920A of the Social Security Act, the last day of the month that follows the
month in which the individual becomes presumptively eligible.
(4) For an individual selected for
coverage under the Qualified Individuals Program, the eligibility agency shall
extend eligibility through the end of the calendar year if the individual
continues to meet eligibility criteria and the program still exists.
(5) The eligibility agency shall complete a
periodic review of a recipient's eligibility for medical assistance in
accordance with the requirements of
42 CFR
435.916, October 1, 2013 ed., which the
Department adopts and incorporates by reference. The Department elects to
conduct reviews for non-MAGI-based coverage groups in accordance with
42 CFR
435.916(a)(3) if eligibility
cannot be renewed in accordance with
42 CFR
435.916(a)(2). The
eligibility agency shall review factors that are subject to change to determine
if the recipient continues to be eligible for medical assistance.
(6) For non-MAGI-based coverage groups, the
eligibility agency may complete an eligibility review more frequently when it:
(a) has information about anticipated changes
in the recipient's circumstances that may affect eligibility;
(b) knows the recipient has fluctuating
income;
(c) completes a review for
other assistance programs that the recipient receives; or
(d) needs to meet workload demands.
(7) If a recipient
fails to respond to a request for information to complete the review, the
eligibility agency shall end eligibility effective at the end of the review
month and send proper notice to the recipient.
(a) If the recipient responds to the review
or reapplies within three calendar months of the review closure date, the
eligibility agency shall consider the response to be a new application without
requiring the client to reapply. The application processing period shall apply
for the new request for coverage.
(b) If the recipient becomes eligible based
on this reapplication, the recipient's eligibility becomes effective the first
day of the month after the closure date if verification is provided timely. If
the recipient fails to return verification timely or if the recipient is
determined to be ineligible, the eligibility agency shall send a denial notice
to the recipient.
(c) The
eligibility agency may not continue eligibility while it makes a new
eligibility determination.
(8) If the eligibility agency sends proper
notice of an adverse decision in the review month, the agency shall change
eligibility for the following month.
(9) If the eligibility agency does not send
proper notice of an adverse change for the following month, the agency shall
extend eligibility to the following month. Upon completing an eligibility
determination, the eligibility agency shall send proper notice of the effective
date of any adverse decision.
(10)
If the recipient responds to the review in the review month and the
verification due date is in the following month, the eligibility agency shall
extend eligibility to the following month. The recipient must provide all
verification by the verification due date.
(a) If the recipient provides all requested
verification by the verification due date, the eligibility agency shall
determine eligibility and send proper notice of the decision.
(b) If the recipient does not provide all
requested verification by the verification due date, the eligibility agency
shall end eligibility effective the end of the month in which the eligibility
agency sends proper notice of the closure.
(c) If the recipient returns all verification
after the verification due date and before the effective closure date, the
eligibility agency shall treat the date that it receives the verification as a
new application date. The agency shall then determine eligibility and send
notice to the recipient.
(11) The eligibility agency shall provide
ten-day notice of case closure if the recipient is determined ineligible or if
the recipient fails to provide all verification by the verification due date.
(12) The eligibility agency may
not extend coverage under certain medical assistance programs in accordance
with state and federal law. The agency shall notify the recipient before the
effective closure date.
(a) If the
eligibility agency determines that the recipient qualifies for a different
medical assistance program, the agency shall notify the recipient. Otherwise,
the agency shall end eligibility when the permitted time period for such
program expires.
(b) If the
recipient provides information before the effective closure date that indicates
that the recipient may qualify for another medical assistance program, the
eligibility agency shall treat the information as a new application. If the
recipient contacts the eligibility agency after the effective closure date, the
recipient must reapply for benefits.