Exparte Reviews

Exparte Reviews 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) closures t, 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.