210-RICR-40-00-2
210-RICR-40-00-2. Application and Renewal Process for IHCC Groups (version Amendment, 03/24/2020 to 02/12/2021)
2.1 Scope and Purpose
In September 2016, the State
implemented its new integrated eligibility system (IES) which has the
capacity to cross-walk with the State’s health insurance
marketplace, HealthsourceRI.gov (HSRI) and, through a single
application process, evaluate eligibility for publicly financed
health coverage and needs-based programs administered by DHS and
other EOHHS agencies. This section focuses on the application and
renewal processes that have been established in conjunction with the
implementation of the IES.
2.2 Access Points
A. The State is committed to
pursuing a “No Wrong Door” policy that offers consumers
multiple application and renewal access points which all lead to the
State’s IES.
1. Self-Service –
Persons seeking initial or continuing eligibility have the option of
accessing the eligibility system on-line using a self-service portal
through links on the EOHHS ( eohhs.ri.gov )
and DHS ( dhs.ri.gov ) websites or
directly through HSRI ( HealthSourceRI.com ).
There are also kiosks located in DHS field offices that provide
direct access to the self-service portal. The information applicants
provide on-line is entered directly into the eligibility system and
processed electronically in real-time. For these reasons, the
Medicaid agency encourages all new applicants to select the
self-service portal option and complete and submit the application
electronically whenever feasible.
2. Assisted Service –
Applicants and beneficiaries may also apply on paper and submit forms
via mail, fax, or e-mail or deliver in person to DHS field offices.
Agency eligibility specialists are available to provide help, as are
HSRI representatives and various certified assisters located at
community agencies. Applications that are completed on paper are
scanned into the IES agency portal.
3. Applicants may submit paper
applications in-person or by U.S. mail, e-mail transmissions, and
facsimile transmissions to the address specified on the application.
Paper applications are available on-line, through the U.S. mail upon
written request, by telephone, or in person at any DHS field office.
Information provided on the paper application is directly scanned or
entered into the eligibility system through an agency portal by
eligibility or LTSS specialists on the applicant’s behalf.
2.3 Application and Renewal
Assistance
A. The State provides
application and renewal assistance through eligibility specialists in
the DHS field offices and HSRI Contact Center and trained assisters,
certified in accordance with 42 CFR 435.908. This assistance must be
provided in a manner that is accessible to persons with disabilities
and those who have limited English proficiency. Information on
obtaining application/renewal assistance is available by calling
855-MYRIDHS (1-855-697-4347) as well as on-line through the DHS, HSRI
and EOHHS websites using the links specified in this section. In
addition, eligibility specialists and certified assisters are
responsible for upholding the following rights of current and
perspective Medicaid beneficiaries:
1. Eligibility and Renewal
Help – Including help provided by DHS, EOHHS, and HSRI
eligibility specialists and certified assisters in completing all
necessary forms, obtaining and submitting required documentation, and
responding to inquiries or requests for information. Assisters may
provide help or act on behalf of the applicant or beneficiary in
dealing with agency representatives, but are not permitted to make
determinations of eligibility.
2. Translation Services –
An interpreter or translator is available to assist in the
application process upon request.
3. Protection of Privacy --
All information applicants provide is kept confidential unless the
agency is otherwise authorized to share with other state and federal
agencies for the purposes of verification and enrollment.
4. Timely Determinations –
Eligibility determinations, including providing a notice of the
agency’s decision, must be made in accordance with the
timelines indicated in § 2.4(A)(8) of this Part.
5. Appeals - The agency
accepts appeals and holds hearings on actions related to eligibility
decisions in accordance with Medicaid Code of Administrative Rules,
Complaints and Appeals, or any successor regulation.
6. Non-discrimination –
Applicants are treated in a manner that is free from discrimination
on the basis of race, color, national origin, sex, gender identity or
sexual orientation, age or disability.
2.4 Completing and Submitting the
Application
A. In general, the process of
completing and submitting an application proceeds in accordance with
the following:
1. Account Creation – To
initiate the application process, a person must create a login and
establish an account in the eligibility system. This can be done
through the self-service portal by the person alone or with the help
of an eligibility specialist or certified assister.
a. Identity proofing. The
applicant must provide personally identifiable information for the
purpose of creating an on-line account as a form of identify proofing
during the process of applying for Medicaid. Verification of this
information is automated. Documentation proving identity may be
required if the automated verification process is unsuccessful.
Acceptable forms of identity proof include a driver’s license,
school registration, voter registration card, etc. Documents may be
submitted via mail, fax, on-line upload, or to a DHS Office.
b. Account matches. Once
identity is verified, account matches are conducted to determine
whether the applicant or members of the applicant’s household
have other accounts or are currently receiving benefits.
2. Account Duration – An
application account is open for a period of ninety (90) days.
Applications may be started at any time. Once started, progress can
be saved at any point and the application returned to at a later
time. Incomplete applications not submitted within ninety (90) days
are automatically deleted in the eligibility system.
3. Application Materials –
The application materials a person seeking Medicaid coverage must
have on hand may vary depending on the application processing flow:
a. MAGI-based eligibility. As
indicated in § 2.6.2 of this Part, applicants who are under
sixty-five (65) are generally evaluated first for eligibility in one
of the Medicaid Affordable Care Coverage (MACC) groups before being
considered for the IHCC groups. The MACC group, MAGI-based
application process is explained in greater detail in Medicaid Code
of Administrative Rules, Application Process. This eligibility
process generally requires applicants to provide information used
when filing federal tax forms and/or documents commonly used for
identification and income verification purposes.
b. SSI-based eligibility. The
IHCC application process builds on the MAGI review unless a person is
65 or older. In all cases, self-attestation of income and resources
begins the process. To the full extent feasible, electronic data
matches are used to verify financial information. Documentation of
certain information may be required, however. In addition, when using
a paper application, access to certain types of materials may be
necessary.
(1) Materials that may be of
assistance in completing the application include, but are not limited
to:
(AA) Federal tax filing status
(BB) Social Security Numbers
(CC) Birth Dates
(DD) Passport or other
immigration numbers
(EE) Federal tax returns
(FF) Information about any
health coverage available to you or your family, including any
information you have about the health insurance your current employer
offers even if you are not covered by your employer’s insurance
plan, Medicare and other forms of coverage
(GG) W-2 forms with salary and
wage information if you work for an employer
(HH) 1099 forms, if you are
self-employed.
(2) Common types of
documentation that may be needed to verify income and resources
include the wage and earning and tax forms noted above and:
(AA) Copies of checks or
receipts for unearned or irregular income
(BB) Bank statements
(CC) Annuity/retirement fund
statements for insurance companies
(DD) Copies of bonds
(EE) Stock ownership
statements
(FF) Copies of life insurance
policies
(GG) Statements from insurance
companies or companies providing annuities
(HH) Copies of burial purchase
agreements.
(3) Common documents that may
be required with respect to self-employment income include:
(AA) Tax forms such as 1040
Schedule ES (Form 1040), Schedule C or comparable State form or
federal return with the "Self-Employment Tax" line
completed.
(BB) Business records if the
applicant has not been self-employed long enough to file taxes,
including financial statements, gross receipts and expenses,
quarterly reports, certified statement form licensed accountant.
(CC) For royalties, honoraria,
and stipends, the nature and amount of payments, any Social Security
of Medicare withholding, dates of payments and frequency of payments,
and/or tax forms above or 1099 MISC and the name of the issuer.
(4) Common documents that are
required related to health status or disability include:
(AA) Authorization to obtain
medical and/or health care records, the names and addresses of the
treating physicians and other providers, health care bills incurred
or paid during the three month retroactive eligibility period, or
that remain unpaid from any previous period.
4. Application Filing Date –
The filing date of an application is the date used to determine when
eligibility begins if it is approved. The filing date is not
necessarily the date an application is complete, but is typically the
date a signed completed application form is submitted through the
self-service portal on-line or date-stamped as received by the agency
or electronic means if uploaded, mailed, faxed, or scanned or
delivered in-person. The filing date may be protected if the
application is not complete due to outstanding verifications or
required reforms. The timeline the agency must meet for making an
eligibility determination does not begin until the date an
application is complete, as indicated below, however.
5. Application Completeness –
An application must be complete before a determination of eligibility
can be made. An application is considered complete when all
information requested, including any ancillary required forms and
authorizations, are date-marked as received by the State. As the
timelines for making a determination of eligibility specified in
subsection (8) below begin on the date the application is complete,
applicants are informed and offered the opportunity to provide any
additional documentation or explanations necessary to proceed to the
determination of eligibility in a timely manner. Such information is
provided to applicants immediately through an electronic notification
from the IES when applying on-line either through the consumer
self-service portal or with the assistance of an agency
representative. In cases in which an agency eligibility specialist
or assister is entering information into an applicant’s account
or scanning a paper application, information about necessary
documentation is generated immediately in the on-line account and
must be made available as soon as feasible.
6. Voluntary Withdrawal –
An applicant may request that an application for Medicaid health
coverage be withdrawn at any time either through their secure on-line
account or by submitting the request in writing via the U.S. mail or
fax to the EOHHS or DHS agency representative. The Medicaid agency
sends a notice to the applicant verifying the time and date of the
voluntary withdrawal and indicating that the applicant may reapply at
any time.
7. Self-Attestation of
Application Information – All questions on the application must
be answered in a truthful and accurate manner. Every applicant must
attest to the truthfulness and accuracy by signing a paper
application in ink or by providing an electronic signature on-line
under penalty of perjury. The IES verifies the information
electronically to the fullest extent feasible and must verify
applicant attestations in accordance with the procedures set forth in
the Medicaid Code of Administrative Rules, Application Process and
Verification.
8. Privacy of Application
Information – Application information must only be used to
determine eligibility and the types of coverage a person is qualified
to receive. Accordingly, the EOHHS, the agencies under its umbrella,
and all other entities serving as its agents in the Medicaid
eligibility process maintain the privacy and confidentiality of all
application information and in the manner required by applicable
federal and state laws and regulations.
9. Eligibility Determination
Timelines – Federal and State law set specific timeliness for
making determinations of Medicaid eligibility. The timelines vary in
length depending on whether a clinical eligibility determination is
required that necessitates a review of information from second
parties (e.g., health practitioner or provider) and/or third parties
(e.g., insurers). In accordance with R.I. Gen. Laws §
40-8.6(b)(2) (Public Law 16-150), the timeline for determining
eligibility begins on the date a completed application, including
any required forms and/or authorizations are received by the EOHHS,
or its authorized eligibility agents, and ends on the date a notice
is sent to the applicant explaining the agency’s decision. The
EOHHS is responsible for processing applications within these time
limits for IHCC group members who have not been deemed or determined
eligible on the basis of participation in another federal program
(e.g., SSI, DCYF Foster Child, etc.). The timelines are as follows:
MACC
and IHCC Eligibility Determination Timelines
Coverage
Group
Determination
Timeline
MACC
Groups
30
Days
Community
Medicaid – Elders 65 and over
30
Days
Community
Medicaid – Adults with Disabilities
90
Days
Sherlock
Plan
If
determination of disability has been made – 30 days
If
determination of disability or level of care is required –
90 days
Medically
Needy – Persons with Disabilities
90
Days
Medically
Needy – No Disability
30
Days
LTSS
90
Days
2.5 Beneficiary Responsibilities
A. Medicaid beneficiaries must
provide accurate and complete information about any eligibility
factors subject to change at the time of the application and annual
renewal. Accordingly:
1. Consent – At the time
of the initial application or first renewal, Medicaid beneficiaries
are required to provide the State with consent to retrieve and review
any information not currently on record pertaining to the eligibility
factors subject to change through electronic data matches conducted
through the State’s eligibility system. Once such consent is
provided, the Medicaid agency may retrieve and review such
information when conducting all subsequent annual renewals.
2. Duty to Report –
Medicaid beneficiaries are required to report changes in eligibility
factors to the Medicaid agency within ten (10) days from the date the
change takes effect. Self- reports are permitted through the
eligibility system consumer self-service portal as well as in person,
via fax, or mail. Failure to report in a timely manner may result in
the discontinuation of Medicaid eligibility.
3. Cooperation –
Medicaid members must provide any documentation that otherwise cannot
be obtained related to any eligibility factors subject to change when
requested by the Medicaid agency. The information must be provided
within the timeframe specified by the Medicaid agency in the notice
to the Medicaid member stating the basis for making the agency’s
request.
4. Voluntary Termination –
A Medicaid beneficiary may request to be disenrolled from a Medicaid
health plan or to terminate Medicaid eligibility at any time. Such
requests must be made in writing and preferably two (2) weeks prior
to the date of disrenrollment or the date a beneficiary seeks to end
eligibility.
5. Reliable Information –
Medicaid applicants and beneficiaries must sign under the penalty of
perjury that all information provided at the time of application and
any annual renewals thereafter is accurate and truthful.
6. Change of Service Delivery
Options – Medicaid beneficiaries may change Medicaid health
plans during the annual open enrollment period. Notice of the open
enrollment period is provided to beneficiaries at least thirty (30)
days prior to the date the period begins. Beneficiaries may also
request to change service delivery options at any other time in
accordance with the procedures set forth in Subchapter 10 Part 1 of
this Chapter, or if MACC group eligible, Medicaid Code of
Administrative Rules, RIte Care Program, Rhody Health Program,
Enrollment, and RIte Share Program.
7. Alternative forms of
Benefits/Assistance – Applicants and beneficiaries must, as a
condition of eligibility, take any necessary steps to obtain
annuities, pensions, retirement and disability benefits along with
any other forms of assistance available for support and maintenance
that may be identified by the agency, in writing, in accordance with
Medicaid Code of Administrative Rules Cooperation Requirements. Good
cause exceptions are considered when requested in writing.
2.6 Application Review Process
2.6.1 Scope
and Purpose
This section provides an
overview of the application review process for all IHCC groups
identified in this chapter and the specific provisions that apply to
Community Medicaid populations subject to eligibility determinations
made by the State. As a result of programmatic changes in the State’s
IES required by the ACA, people are no longer required to apply for
one particular category of Medicaid eligibility. Instead, to maximize
access and choice, applicants are evaluated across a variety of MACC
and IHCC pathways which apply different eligibility standards,
requirements, and criteria. In short, the denial or termination of
eligibility in one category does not preclude eligibility through
another pathway. The State must consider all bases of eligibility.
2.6.2 Conversion
Process
A. The conversion to the
State’s new application review process requires new applicants
and existing beneficiaries to be treated differently during the
initial stages of implementation. A “new applicant”, for
these purposes, is a person who is not currently receiving Medicaid
health coverage in any eligibility category. The conversion process
is as follows:
1. New Applicants – New
applicants are evaluated first using the MAGI methodology for the
MACC groups.
2. Existing Beneficiaries –
At the time of renewal, current IHCC beneficiaries are evaluated
using the SSI income and resource standards to ensure continuity of
coverage. In the process of this evaluation, an ancillary review of
the information in the beneficiary’s account along with updates
from all available data sources is conducted to determine whether
MAGI-based eligibility in one of the MACC groups is available. This
review is only conducted if the beneficiary is under age 65 or 65 and
older and the parent/caretaker of a Medicaid-eligible child. Upon
completing this review, a notice is sent to the beneficiary
indicating if an alternative form of coverage is available.
2.6.3 General
Rules
A. To the extent feasible, the
person seeking initial or continuing eligibility is provided with the
choice of eligibility pathways within and, in some instances, across
the MACC and IHCC group categories. Again, MACC group eligibility is
primarily income-based and uses the MAGI standard established in
conjunction with federal health care reform. IHCC group eligibility
is much more varied and, when not automatic due to participation in
another federal program or special requirements, is based on both the
SSI methodology and SSI-related characteristics. As there are
significant distinctions between these two categories for obtaining
eligibility, when choosing a pathway, the following should be taken
into consideration:
1. Limits on Choice –
Although the scope of primary care essential health coverage across
Medicaid in the broad IHCC and MACC categories does not significantly
vary, there are certain differences that may affect a person’s
choice of or access to certain eligibility pathways. In addition,
federal and State policies also impose restrictions. The most common
include:
a. Retroactive coverage. Under
the State’s Section 1115 demonstration waiver, retroactive
coverage is not available to MACC group beneficiaries, including
those who qualify for LTSS. Retroactive coverage is an included
benefit through many of the IHCC pathways in which the State
determines eligibility for Community Medicaid and Medicaid LTSS, as
indicated in Subchapter 5 Part 3 of this Chapter.
b. Other Health Coverage.
Federal law precludes persons who are eligible for or enrolled in
Medicare from obtaining coverage through the MACC group for adults,
ages 19 to 64. Other forms of health coverage, including both
commercial insurance and government-sponsored, are generally not a
bar to Medicaid eligibility through the MACC and IHCC pathways. In
addition, the State’s health insurance payment program –
RIte Share – makes it possible for beneficiaries who have
access to cost-effective Employer-Sponsored Insurance (ESI) to
maintain coverage through work once they become Medicaid-eligible.
Medicaid Code of Administrative Rules, RIte Share, provides details
on RIte Share. The MPPP is also available to provide financial help
to cover the costs of Medicare coverage for low-income elders and
adults with disabilities.
c. Former SSI Recipients. All
former SSI recipients who lose cash benefits due to increases in
income are evaluated first for the SSI protected status groups
located in Subchapter 5 Part 1 of this Chapter. In instances in which
eligibility in one of these groups is unavailable, the person will be
evaluated for the MACC and/or IHCC Community Medicaid pathways, to
the extent the other limiting factors in this subsection allow, and
provided with a choice of coverage options as appropriate.
d. Age. In general, persons 65
and older are ineligible for MAGI-based MACC group eligibility.
Parents/caretakers of a Medicaid eligible child in this age group,
including those enrolled in Medicare, are the only exceptions.
Children and youth under 19 are generally not eligible in the IHCC
groups. However, pregnant women, parents/caretakers and children with
high health care expenses who have family income above the MACC group
limit may seek MN eligibility through Community Medicaid using the
SSI methodology. IHCC resource and deeming rules apply, unless the
child is seeking LTSS through the Katie Beckett eligibility
provision.
e. LTSS Preventive Level
Services. These services are only available to adults with
disabilities and elders who are eligible through the Community
Medicaid pathways as EAD or MN.
f. Need for LTSS. All LTSS
applicants are subject to a review of the transfer of assets, in
accordance with applicable federal requirements and State laws and
regulations governing estate recoveries, irrespective of whether
initial income eligibility is determined using the MAGI standard or
the SSI methodology. LTSS beneficiaries who are eligible through the
MACC group pathway ARE NOT subject to resources limits, however.
g. Medically Needy (MN)
Eligibility. For all non-LTSS applicants, MN eligibility is
considered the last option for obtaining Medicaid coverage, both
because the burden on beneficiaries is the most significant and the
opportunities for coordinating and managing care are so limited.
There is not a MN option for MACC group adults, unless they are
eligible through the pathway for parents/caretakers. Accordingly, for
these adults IHCC eligibility is the only avenue to MN coverage. For
LTSS applicants, MN eligibility is also the last option; though the
income eligibility limits are higher than through other eligibility
pathways, beneficiary liability tends to be as well. In addition,
access through this pathway limits access to SSP assistance (i.e.,
only available if income is at or below 300% of SSI) and the range of
LTSS settings in some instances.
h. MPPP. Elders and adults
with disabilities who are participating in the MPPP are only eligible
for the MACC group for parents/caretakers. Otherwise, MPPP
participants must access Medicaid financial help through the IHCC
groups. In addition, participation in the MPPP has the potential to
affect eligibility for Medicaid health coverage through the Community
Medicaid MN pathway. As indicated in Subchapter 5 Part 2 of this
Chapter, Medicare premiums are health expenses that count toward the
amount a person must spenddown in order to obtain Medicaid coverage
during the six month MN period. MPPP participants are not permitted
to use these expenses toward a spenddown as they are paid by the
State.
2. Eligibility Across Pathways
– Eligibility specialists and application assisters must be
available to provide applicants and beneficiaries with information
about the impact the limits above have on the choice of eligibility
pathways. Such information is also provided with paper applications
and will be built into the self-service portal to assist applicants
and beneficiaries in making reasoned choices about their Medicaid
health options. The table below summarizes the major cross pathway
eligibility opportunities by major Medicaid populations.
Selected Eligibility
Cross Pathways By Population
(Excludes
beneficiaries eligible on basis of other programs)
Population
MACC Group –
MAGI-Based
(No Retroactive
Coverage)
IHCC Group SSI
methodology-based
(Retroactive
Coverage Possible)
Both MACC and IHCC
Eligibility determined using both
Children, no need
for LTSS
Up to MACC income limit
(261% of FPL +5% disregard)
MN only if income above
MACC limit and have high health expenses
Not Applicable
Child requiring
LTSS-health institution over 30 days
Not applicable
MN-LTSS
Not Applicable
Child requiring
LTSS-HCBS
Up to MACC income limit
for children
Family income above
MACC limit – Katie Beckett eligibility based on child’s
income only
MN-LTSS
Not Applicable
Pregnant Women
Up to MACC income limit
(253% of FPL + 5% disregard)
EAD or MN if disabled,
but only until next renewal or birth of baby, whichever comes
first;
MN if non-disabled and
income above MACC limit and have high health expenses
LTSS
Option for MACC and
MPPP if have Medicare
Adults 19-64, no
Medicare
Up to MACC income limit
(133% FPL + 5% disregard),
LTSS with no resource
limit
EAD or MN if have a
disability and are seeking retroactive coverage
LTSS
Not Applicable
Adults with
disabilities 19-64
If no Medicare, up to
MACC limit for adults, including while awaiting a disability
determination by the State or SSA
EAD, MPPP and/or MN
Sherlock Plan if
working
LTSS
Option MACC group for
parents/caretakers and MPPP
Elders
Only if a
parent/caretaker
EAD, MPPP, MN
LTSS
Option MACC group for
parents/caretakers and MPPP
3. Continuing Eligibility
Reviews Prior to Termination of Coverage – The State must
evaluate whether a beneficiary may qualify for Medicaid health
coverage through an alternative pathway prior to the termination of
eligibility. This requirement only applies when the reason for the
termination is a change in an eligibility factor (e.g., age, income,
resources or disability, relationship, etc.). The State uses any
information known about the beneficiary through his or her account
and electronic data sources to evaluate the options for continuing
coverage. A beneficiary is informed in writing about this evaluation,
which is referred to as an ex parte review, and of any additional
materials that must be submitted to determine whether alternative
forms of eligibility exist at least ten (10) days prior to the date
the eligibility termination takes effect. Such notification is
provided more than thirty (30) days in advance of the date of the
agency action whenever feasible. In addition to evaluating
beneficiaries for other forms of Medicaid eligibility, anyone under
age 65 is also considered for commercial coverage with financial help
through HSRI.
2.7 Renewal of Eligibility for
IHCC Groups
2.7.1 Scope
and Purpose
A. One of the principal
requirements of Medicaid is that continuing eligibility must be
re-evaluated at least once a year. For the IHCC groups, this annual
review was called a “redetermination” and, accordingly,
often required beneficiaries to reapply for coverage. Current federal
regulations [42 CFR 435.916(b)] governing the IHCC groups now require
that these annual reviews consider only those eligibility factors
that are subject to change. Accordingly, the continuing eligibility
of the IHCC group beneficiaries receiving Community and LTSS Medicaid
is now conducted by requiring them to review their account
information on key eligibility factors, as updated by internal and
external data sources, and report any inaccuracies or changes in the
manner described in this section.
B. The factors subject to
change include income, resources, household composition (e.g., as a
result of births, deaths, divorce, etc.), disability or clinical
factors, access to third-party coverage, and changes in family size
(e.g., due to death, marital status, birth or adoption of child),
and/or immigration status. LTSS beneficiaries may be required to
provide additional information related to change in care settings.
Note: The provisions in this section do not apply to beneficiaries
who are deemed eligible due to participation in other programs (e.g.,
SSI recipients), or that are determined eligible by the SSA. Special
MPPP renewal provisions also apply.
2.7.2 Agency
Responsibilities
A. IHCC group renewals are
conducted in accordance with the following unless EOHHS postpones
processing of annual Medicaid eligibility renewals that fall during
the novel Coronavirus Disease (COVID-19) declaration of emergency for
sixty (60) days or until the termination of the novel coronavirus
declaration of emergency, whichever is longer. This includes the
suspension of periodic data checks for unemployment, SWICA, TALX and
other sources and suspension of quarterly post-eligibility
verifications:
1. Frequency – The
Medicaid renewal process occurs at least once every twelve (12)
months and no more frequently unless as result of a change in
eligibility factors.
2. Types of Information –
The eligibility renewal is based on information already available to
the full extent feasible. Such information may be derived from
reliable sources including, but not limited to, the beneficiary’s
automated eligibility account, current paper records, or databases
that may be accessed through the IES. Information about eligibility
factors that are not subject to change or matters that are not
relevant to continuation of Medicaid eligibility are not requested or
used at the time of renewal. Factors that are not subject to change
include, but are not limited to, U.S. citizenship, date of birth, and
Social Security Number.
3. Notice – Timely
notice must be provided of:
a. Renewal Date. A notice of
the date of the annual renewal is sent at least thirty days (30) days
prior to the renewal date. The beneficiary is also provided with a
pre-populated form containing information from the Integrated
Eligibility System and other sources on each relevant eligibility
factor. In instances in which the Medicaid beneficiary is required to
take action in addition to completing the pre-populated form, such as
providing paper documentation or explaining a discrepancy, a timeline
is included for completing the action as well as indication of the
consequences for failure to do so.
b. Renewal Action. At least
ten (10) days prior to the renewal date, Medicaid beneficiaries are
provided with a notice stating the outcome of the renewal process and
explaining the basis for any agency action – continuation or
termination of eligibility. The notice also contains the right to
appeal and obtain an administrative fair hearing. Beneficiaries are
also notified that they have the right to have their health coverage
continued while awaiting a hearing if an appeal is filed in ten (10)
days from the date of the renewal notice is received. The date the
notice is received is presumed to be five (5) days from the date on
the notice.
4. Consent – At the time
of initial application, Medicaid beneficiaries sign or provide an
electronic signature giving the State consent to obtain and verify
information through external data sources and from certain providers
for the purposes determining eligibility and renewing health
coverage. The first time IHCC group beneficiaries are renewed through
the IES, such consent must be provided if it does not already exist.
5. Modified Passive Renewal –
All IHCC beneficiaries are subject to a modified passive renewal
process that proceeds as follows:
a. Initial Automated IES
Renewal. During the first automated IES renewal, IHCC beneficiaries
are provided with a pre-populated form containing all information
related to eligibility on record, typically in their IES accounts,
that has been self-reported and/or obtained through electronic data
matches at application, post-eligibility verification, and change
reports. Beneficiaries are required to review this form, make any
necessary changes and required actions, and then attest to the
accuracy and completeness of the information provided on any
eligibility factor subject to change. In addition, the Medicaid
beneficiary must provide consent to the EOHHS permitting automated
data exchanges and/or retrieval of information on eligibility factors
from outside sources for all future renewals.
b. Continuing Renewals. After
the initial automated renewal, IHCC beneficiaries receive a
pre-populated form and are only required to return the form to
self-report changes in eligibility factors or to respond to agency
requests for information or documentation. If no such changes are
required, the beneficiary is not required to take further action.
Medicaid health coverage is renewed automatically and a new
eligibility period is established.
2.7.3 Beneficiary
Responsibilities
Medicaid beneficiaries must
meet the requirements associated with making and completing an
application as set forth in § 2.5 of this Part.