Family and Children's Medicaid MA-3410 TERMINATIONS, DELETIONS AND EX PARTES
III. REQUIREMENTS FOR EX PARTE REVIEW WHEN an individual becomes Inelgible for Medicaid or WOrk FIrst
A. Whenever a change in situation causes an individual to become ineligible for Medicaid or Work First, complete an ex parte review to evaluate for Medicaid in any possible aid program/categories. Refer to II.A. for the exceptions. The possible aid program/categories are listed below. Citizenship/identity documentation is not required during an ex parte review.
1. Family and Children’s Medicaid
a. MAF-C including,
(1) MAF-C for Job Bonus (MAF-C), refer to MA-3300, Income. Ensure you evaluate under both budgeting methodologies in MA-3300, Income.
(2) MAF-C, refer to MA-3405, Twelve Months Transitional Medicaid.
(3) Caretaker relative of an individual under age 19.
b. Four Month Transitional Medicaid (AAF payment type 4). Refer to MA-3400, Four Months Transitional Medicaid.
c. MIC-N for individuals under 19.
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(III.A.1.c.)
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(III. A. 2.)
b. MAD when anyone in the assistance unit receives Social Security disability, or there is a DMA-4037 in the record indicating that an individual has been determined disabled and the disability has not been subsequently denied/terminated. (For HCWD see MA-2180.)
c. MAD for SSI children with protected status. Refer to the Adult Medicaid manual, MA-2525, Disability.
A child with protected Medicaid status must be covered in MAD-N if he meets the eligibility criteria for MAD-N. Authorize the child in a Family & Children's Medicaid category only if he is ineligible for MAD-N.
A child with protected Medicaid status who is turning age 18 must have a disability review by Disability Determination Services to determine if he meets the adult disability criteria. Follow procedures in MA-2525, Disability, for a disability review.
d. MAB when anyone in the assistance unit meets Social Security’s definition of blindness. Refer to the Adult Medicaid manual, MA-2530, Blindness (For HCWD see MA-2180)
3. If the individual/family is ineligible under categorically needy requirements, evaluate eligibility for Medically Needy under all coverage groups in which he can be included.
a. If the individual is eligible for Medicaid but must meet a deductible, contact the recipient regarding his old, current and anticipated medical expenses to determine if he can meet the deductible. The deductible can be met if:
(1) His deductible amount is $300 or less, or
(2) His old, current and anticipated medical expenses are within $300 of meeting the deductible.
b. Follow EIS instructions to establish the necessary case. If the individual is also eligible for FPW, process the MAF-D case. The applicant/recipient may choose to either receive or not to receive FPW while the application/redetermination is pending to meet a deductible. Explain to the a/r expenses that can be used toward a deductible. An a/r may have one active and one pending application in EIS.
Follow EIS procedures in EIS USER’S MANUAL Section 2012 when the a/r meets the deductible or is approved for disability. Send an adequate notice to terminate the FPW case. Terminate the MAF-D case when the a/r meets the deductible.
c. If it is determined that the individual's deductible is greater than $300 or his old, current and anticipated medical expenses are not within $300 of meeting the deductible, send timely notice to propose termination. If eligible for FPW, send appropriate notice. Establish case in EIS if eligible.
4. Refugee Medical Assistance (RMA) if the family/individual is a refugee and not eligible under any aid program/category. Refer to the RMA manual.
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(III.)
B. Begin the evaluation for ongoing Medicaid as soon as it is determined that the family/individual is ineligible.
C. Do not require a signed application or redetermination document.
D. Unless questionable, consider information obtained at the last Medicaid/Work First review as current. Information from a previous review is not current for MIC/NCHC reenrollments.
E. Verification Requests
1. Reverify only those eligibility factors that are subject to change: such as;
a. Income,
b. Household composition or
c. Resources.
2. Do not reverify factors that are not subject to change, such as
a. Date of birth
b. Citizenship.
3. Information must be obtained from an active agency file. An active agency file includes:
a. An active case or
b. A pending application within the DSS agency or
c. An FNS case in suspense
4. The information must be current. Current information means it was obtained and verified:
a. In another program or
b. In another Medicaid case and
c. Within the time frames for redeterminations of eligibility for the Medicaid coverage group being considered. Time period is determined by the certification period for the program being evaluated. These time frames apply to all sources of information, including SDX.
Example: If the recipient is being evaluated for MAF Medically Needy and the certification period is 6 months, the information must have been verified within the last 6 months. If the recipient is being evaluated for MIC and the certification period is 12 months, the information must have been verified within the last 12 months. In both of these situations the other program must be active, pending or an FNS case in suspense at the time the information is obtained.
5. Information obtained from a closed or terminated program can not be used even if verified during the appropriate time frames.
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(III. E.)
6. Available to the agency includes information available through automated queries, such as:
a. THE WORK NUMBER
b. SDX
c. BENDEX
d. OLV
e. FSIS
f. SOLQ
g. ESC or
h. Other reliable internet based sources of employment and wage verification. (Refer to MA-3515, Automated Inquiry and Match Procedures, and EIS Manual 1100 Volume I for instructions on using the SDX, BENDEX and other online inquiries.) and
i. Information collected in the determination of eligibility for other programs if the information can be released by the other programs within its rules for confidentiality, such as:
(1) Food and Nutrition Services
(2) Work First
(3) Child Care Assistance
(4) IV-D- Child Support Services
(5) Adult or Children Services
7. If the names of immediate family members (spouse, parents and stepparents, adult or minor children, and siblings) who live with the individual are known, check all records in their names and complete on-line matches. See DMA-5138, Non MIC/NCHC Ex parte Checklist and the DMA-5075, Verification Checklist for MIC/NCHC Re-enrollments. for a checklist to document family members.
8. Contact the casehead if additional verification is needed which is not available to the agency. Contact may be by telephone or in writing. If a telephone request is made, advise the casehead what information is needed and that he may request additional time or assistance in obtaining necessary information.
9 Document the record to show the date of the telephone contact, the specific information requested and that the recipient was offered assistance. If the request is in writing, use the DMA-5097, Request for Information.
a. Explain to the casehead that he is responsible for providing necessary verification within 12 calendar days of the request. If the casehead needs more time, allow another 12 calendar days.
b. If verification is not received, send a timely notice proposing termination for failure to provide necessary information. Failure of the caretaker to return requested information does not affect continuous eligibility for the children.
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(III. E. 9.)
c. Timely notice can be sent no earlier than the workday following the due date on the DMA-5097, Request for Information.
d. Do not terminate an individual for failure to provide information unlikely to change or for information that is available to DSS.
F. If the entire case or individuals in the case are ineligible for ongoing Medicaid in any aid program/category including Adult Medicaid or NC Health Choice, document the record and send a timely notice to terminate Medicaid.
G. If ongoing eligibility is established, continue with the remainder of the current certification or payment review period or a new certification period if needed. A new certification period is needed if the current one has expired. The length of the new certification period is based on the aid program/category. Refer to MA-3425, Certification and Authorization.
For example, establish a 12 month certification period for MIC or Health Choice, 6 month certification period for MAF-M or MAD, or through the post-partum period for MPW.
H. If eligibility cannot be established in the timeframe, extend eligibility one month at time until eligibility is established for all Medicaid aid program/categories. Ensure the appropriate notice is mailed prior to termination.
I. Continued Coverage of Pregnant Women Who Lose Eligibility in an Aid Program/Category Other Than MPW
1. A woman who is pregnant and who loses eligibility in any aid program/category (including adult Medicaid as well as Family & Children's categories) may be eligible for continued coverage through the postpartum period under MPW if her countable income as determined by MPW policy does not (or at any time during her pregnancy did not) exceed the MPW income limit.
a. If it is known and verified by the agency that the recipient is pregnant, evaluate for MPW.
b. If pregnancy verification is not contained in the agency records, contact the recipient to request verification of pregnancy (refer to DMA-5137, Ex Parte Verification of Pregnancy). Allow 12 calendar days to provide verification of pregnancy. If more time is needed to get verification, allow an additional 12 calendar days.
If there is no information in county records to indicate pregnancy, do not evaluate for MPW.
NOTE: This does not apply to individuals terminated from SSI. Refer to MA-1000 of the Adult Medicaid Manual for requirements for SSI ex parte reviews when a pregnant woman is terminated from SSI.
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(III.I.)
2. Certain terminations also cause ineligibility for MPW. These include (but are not limited to):
a. The woman moves out of state; or
b. The woman becomes an inmate of a public institution; or
c. The woman, if age 21 or older, is an inpatient in a private psychiatric hospital.
3. Work First or MAF-C or N Terminations
a. Certain pregnant individuals will be eligible for MPW based on information already verified. These are cases in which:
(1) A Work First or MAF-N or C assistance unit includes a woman who is pregnant (the postpartum period is included as part of the pregnancy); and
(2) A change causes the case to be ineligible or the pregnant woman to lose eligibility; and
(3) The change would not cause a loss of benefits under MPW regulations
b. Examples of situations which might terminate Work First or MAF-C or N but would not affect MPW eligibility include, but are not limited to:
(1) Failure to come in for a redetermination, or
(2) Increase in income or resources, or
(3) The case goes into deductible status for MAF; or
(4) For Work First families:
(a) Failure to follow SFU requirements, or
(b) Failure to return a quarterly report, or
(c) Failure to sign the Mutual Responsibility Agreement, or
(d) Failure to register with ESC for First Stop, or
(e) Move from one county in NC to another, or
(f) Termination due to an electing county requirement, or
(g) Expiration of the 24/60 month time limit, or
(h) Expiration of the Benefit Diversion period, or
(i) Failure to comply with pay-after-performance requirements.
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(III.I.3.)
c. Evaluation for pregnant woman coverage for MAF-C or N or Work First terminations.
(1) Determine whether the entire case should receive continued Medicaid based on:
(a) 12 month Transitional Medicaid (MA-3405, Twelve Months Transitional Medicaid
(b) 4 month Transitional Medicaid due to child or spousal support (MA-3400, Four Months Transitional Medicaid).
(2) If the case qualifies for one of these Medicaid continuations, follow procedures in those applicable sections. At the end of the continuation period, follow procedures in those sections to determine whether the case includes a pregnant woman who should be transferred to MPW.
(3) If the entire case does not qualify for one of these Medicaid continuations, and the pregnant woman meets all the requirements in MA-3240, Pregnant Woman Coverage, the county dss must authorize Medicaid for the pregnant woman under MPW
4. Procedures to continue pregnant woman’s Medicaid under MPW:
a. Send a timely notice to terminate current coverage and authorize MPW. (MPW is a lesser benefit as it covers only pregnancy related services).
b. Establish an MPW certification period beginning the month following loss of MAF or Work First authorization through the last day of the month of the postpartum period.
c. Follow instructions in the EIS User’s Manual to terminate the Work First or MAF case or delete the pregnant woman and transfer her to MPW.
d. If the pregnant woman is receiving in a category that does not allow a transfer to MPW, terminate or delete her from the original case and enter an administrative application to authorize MPW. No signed application is required.
J. Benefit Diversion / Open Shut
1. When Benefit Diversion ends, evaluate the family for ongoing Medicaid.
a. Whenever possible, an ex parte review should be completed prior to the end of the Benefit Diversion timely notice period. If eligible for Medicaid, authorize assistance in the appropriate aid program/category.
b. If ineligible for Medicaid or the ex parte review can not be completed before Benefit Diversion benefits are terminated, authorize the family for MAF-C.
(1) The MAF-C certification period is 2 months.
(2) Complete the ex parte review as soon as possible after transfer to MAF-C.
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(III.J.1.b.)
(3) Ensure that all other aid program/categories including Families and Children, NC Health Choice, and Medicaid for the Aged, Blind, and Disabled are considered.
(4) If eligible for Medicaid, authorize assistance in the appropriate aid program category.
(5) If ineligible for Medicaid, send timely notice to terminate assistance.
2. Timely notice should be sent as soon as ineligibility for Medicaid is established.
3. A second party review is required whenever an individual/family is terminated from Benefit Diversion and not authorized for ongoing Medicaid.
