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Staff Tools | GA Program Manual | F. Issuing Benefits
and Changes
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DHS home | SPD
Staff Tools | GA Program Manual | F. Issuing Benefits
and Changes
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Individuals report changes in their circumstances by telephone, office visit, report form or other statements made in writing. The change is considered reported the day it is received by the Department. When a change is reported for one program, consider it reported for all programs in which the individual participates.
Individuals must report most changes within 10 days of their occurrence. The 10-day time frame starts when the change occurs, with two exceptions:
Sometimes the action is simply to note that a change was reported, because it does not affect the benefit amount. Other times, the action will be to recalculate benefits and send the appropriate notice.
Click here for information on reporting changes when the individual is in the MRS.
Individuals are required to report within 10-days all changes in income, resources and circumstances that may affect their eligibility for benefits or the amount of benefits they receive.
Issuing benefits is a separate function from eligibility determination. Consider the security of the benefits and the household’s circumstances in determining the appropriate method of issuing benefits.
Local offices designated to determine eligibility in specific areas and programs have the sole responsibility to authorize benefits. Branch staff is responsible for determining need, establishing eligibility and authorizing benefits.
Determine if the need group is eligible for benefits before benefits are authorized. Notify the individual when benefits are approved either by computer issued notice or SDS 541 generated by ACCESS or hand written.
For more information on issuing benefits, go to Generic Program Elements C.3 through C.13.
GA eligible individuals receive the Plus Benefit Package as their medical coverage. For more information on benefit packages, see the OMAP Worker Guide, Section 4.
The legislature determines what services can be paid for in the benefit package and sets the cutoff point on the prioritized list (click here to view the prioritized list). Medical conditions paired with their recommended treatment are prioritized.
Cash benefits. The effective date is whichever of the following comes first:
Medical benefits. The effective date is whichever of the following occurs first:
Cash: 461-180-0070
Medical: 461-180-0090
The effective date is the day that an action will be taken or a change made on a case. When a change is not made on a case by the effective date, make the change as soon as possible and supplement benefits for the current month, restore lost benefits for past months, or write an overpayment as appropriate.
The effective date for an action is determined by the type of action and the reporting system.
Actions to close or suspend are effective on the last day of the month in which the notice period ends. The effective date for denying benefits is the earlier of the following:
Use the SDS 540 and SDS 1003 when denying a individual that does not meet the disability requirements.
Changes causing increases can have different effective dates, depending on when the individual reports the change and whether it has to do with adding a person. If the individual reports the change prior to the month in which it will occur, the effective date is the first of the month in which it will occur, unless the change is for adding a person.
When they report the addition of a person, the effective date is the date on which all eligibility requirements are met and verified. If benefits have been issued for the month and adding the new person would reduce benefits, add the person the first of the following month. When the change is not reported until the month it occurs or later, the effective date is the first of the month following the date the change was reported.
Changes causing reductions are effective the first day of the month after the 10-day notice period expires. If the change will end benefits, the effective date is the last day of the month in which the 10 day notice period expires.
Since very few GA individuals are in the MRS, please refer to the rule specific to the type of action for information on the effective date for people in the MRS.
Adding person: 461-180-0010,
Removing person: 461-180-0120
Increases: 461-180-0020,
Reductions: 461-180-0030
Closing/suspending: 461-180-0050,
Denial: 461-180-0060
Effective Dates for Special Circumstances. Situations that are exceptions to the effective dates described above are:
Disqualifications: End a disqualification for failing to enroll in cost-effective, employer sponsored health insurance the day the individual provides verification that they have enrolled during the open enrollment period. All other disqualifications end whenever the individual agrees to cooperate. 461-180-0065
Lump-Sum ineligibility: The start date for the ineligibility period due to a lump-sum payment is the corresponding payment month in which the lump-sum is received. 461-180-0095
Reductions pending a hearing decision: Use the original effective date as given in the continuing benefit decision notice. 461-180-0105
Restored benefits: When individuals are underpaid benefits or have benefits denied or closed in error, they are entitled to a late payment for the benefits they should have gotten. This late payment is called a restoration of lost benefits. When a Department error caused the underpaid benefits, the effective date of restoration is the date the error was made, up to a maximum period of 12 months. 461-180-0130
When a client error caused the underpaid benefits, the effective date is the earlier of the month the individual notifies the Department of the error, the month the agency discovers the error, or the date of a hearing request.
Suspension (ending): If the suspension is for one month, the effective date is the month after the one-month suspension. If the suspension is for more than one month, the effective date for restoring benefits is the date the benefit group again becomes eligible.
Changes in special or service need: The effective date for a special need is the date of request for the special need item.
The effective date for long-term care is the date the service plan is implemented. A service plan is considered implemented when:
Payment for long-term care will be authorized:
The effective date for a termination of or a decrease in service or a special need is the later of the following:
See 461-180-0110 for the effective date for employer-sponsored health insurance premiums
Ending DQ: 461-180-0065,
Restorations: 461-180-0130
Reductions Pending Hearing: 461-180-0105
Lump-Sum: 461-180-0095,
Special Needs: 461-180-0040
At initial application, a filing group is approved for benefits for a specific certification period. Prior to the certification period expiring, it is time for a redetermination of eligibility to approve or deny continuing benefits.
The redetermination is required not only when the certification period expires, but also at any other time the Department determines that eligibility for benefits is questionable. Therefore, redetermination period means the months between initial eligibility and when the certification expires, or the months between one redetermination and the next.
The redetermination process involves review of the application and supporting verifications. Individuals must cooperate in the redetermination. Failure to do so, causes ineligibility and benefits are stopped.
Redetermine eligibility at least once every 12 months. When the group also receives FS, set the period so that eligibility for GA and FS will come up for review at the same time. This allows individuals to apply for multiple program benefits on one application.
The effective date for continuing eligibility at the end of the redetermination period is one of the following:
Give the filing group 45 days from the date that the client contacts the Department to re-establish their eligibility under the same or a different medical program. If all necessary eligibility information is received prior to the end of the 45-day period, take the appropriate case action (continue current medical eligibility, change program, end benefits) and send appropriate decision notice(s). If the filing group does not establish eligibility (by responding to pended items, etc.) within the 45-day time limit, end medical benefits and send a decision notice.
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Redetermination Period: 461-115-0430
Effective dates; Redeterminations: 461-180-0085
Effective Dates; Elig. following closure: 461-180-0100
The interview requirements for a redetermination are much like the ones for an initial application. All interviews are conducted by an employee of the local office and must protect the individual’s right to privacy and confidentiality. An interview is needed for GA clients once every 12 months.
Interviews should be scheduled as promptly as possible to ensure compliance with the application processing time frames. Interviews may be at the branch office, out of the office or by phone. Phone interviews should only be used if branch office or out-of-office interviews are not possible.
