For general information on issuing benefits, see GPE Section C.
For more information on reporting changes, see GPE Section E.
Clients are required to report, within 10 days, changes in:
Acting on reported changes. If acting on a reported change that affects medical eligibility, give the filing group 45 days from the date the change is reported by the household or other state agency to re-establish their eligibility under the same or a different medical program. The client's report of the change must be timely in order to get the 45-day extension.
If all necessary eligibility information is received prior to the end of the 45-day period, take the appropriate case action (change program, end benefits, etc.) and send a decision notice and 462 (if necessary).
If the Department needs additional information to act on the timely reported change, the benefit group remains eligible from the date the change was reported until the Department determines eligibility in accordance with the application processing time frames in 461-115-0190. See below for use of the BED code while an OHP case is pending review.
If they do not establish eligibility (by responding to pended items, etc.) within the 45-day time limit, take the appropriate case action (change program, end benefits, etc.) and send a decision notice and the appropriate 462 (if necessary).
See SPD WG B.7 for more information on reviewing for all medical programs.
When reviewing an ongoing medical case (except for periodic redeterminations) use the date of the review as the first of the 45 days.
Reporting changes timely: 461-170-0011
Acting on reported changes: 461-170-0130
Redetermination is the process used to review eligibility to approve or deny the continuation of benefits. This process includes a review of the new or existing application and supporting documentation. It also includes an evaluation of eligibility for all medical programs prior to ending benefits.
Redetermination is done at assigned intervals, whenever eligibility becomes questionable or when acting on a change that affects current medical eligibility. OHP redeterminations are based on the OHP certification periods.
When completing a redetermination for OHP, if the client does not establish a date of request by returning the application materials, phone call, office visit, written note or other method of contact prior to benefits ending, do not pend the client for 45 days. The CM system will automatically send a decision notice to close and end benefits.
No new application at redetermination. Clients who are receiving a DHS medical program do not need to complete a new application at redetermination. Additionally, for clients selected from the Reservation List who are receiving other program benefits, a new application is not required if eligibility can be determined by amending the application on file.
It does not matter when the application was originally signed, as long as the client is currently receiving DHS program benefits at the time they make the request for medical. Review the existing information and update as necessary. Determine what eligibility items need to be verified and send a pend notice.
Process. If the client does contact the Department prior to benefits ending (to request additional time to turn in the application or otherwise establish a new date of request), 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 you need additional information to make the medical eligibility decision, pend the case for 45 days and add the BED need/resource item to the CM case to prevent automatic closure. The Bypass End Date (BED) coding works correctly only when there is a medical end date to bypass. For the BED end date, add the month that includes the end of the 45 day pend period AND the 10-day notice period in case you need to reduce or close medical benefits.
If the client doesn't respond to the pend, the CM system will automatically send the "CR" close notice to tell the client their medical will end because the review of their eligibility wasn't completed. During end of month processing, it will close the CM case automatically based on the BED need/resource end date.
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 and 462 (if necessary).
If enough information is available to determine eligibility and the client is no longer eligible, consider if you have enough time to send a timely continuing (10-day) close notice. If you have enough time, send the 10-day notice explaining the specific reason they are no longer eligible for their current medical benefits (over income, over resource, etc.). You'll also need to send a DHS 0462A or 462S multiple medical program denial notice.
If there isn't enough time to send the 10-day close notice but you know there is no longer any medical program eligibility, add the "BED" (Bypass End Date) need/resource item to the client's CM case. The BED need/resource will tell the CM system that the case should stay open until the BED end date. Use the next month as the BED need/resource end date. After end of month processing, close for the end of the following month, send the 10-day notice and the DHS 0462A.
If eligible for OHP, any month the client receives benefits because the case had been eligible with a BED code counts toward the next certification period.
When recertifying a BED case, remove the BED code. Enter a Compute action for the first of the next month. Change the medical case descriptor if necessary and update the OPC, OP6, CHP or OPU need/resource end date. Change the medical start date on CMUP for the recertified client to the first of the next month.
For example, an OPC child's certification is due to end April 30. On April 14, the family reapplies for OHP benefits and the case is in BED status for 06/09. On May 5, the child is determined to be eligible for CHP. Remove the BED code. Compute for June 1, 2009, and enter a CHP need/resource end date of 04/10. Change the child's medical start date to June 1.
Date of request : 461-115-0030
Certification Period: 461-115-0530
Effective dates; Redeterminations: 461-180-0085
Initial month medical benefits or adding a new person to an open case. If the client completes the application within the time period described in 461-115-0190 it is the date of request or, if the client does not meet all eligibility requirements on the date of request, first day following the date of request on which all eligibility requirements are met.
Adding a New Person: 461-180-0010
Initial Month: 461-180-0090
Closing benefits. The effective date for clients that become ineligible is:
Suspending Benefits for incarcerated clients: The effecive date for suspending benefits for a client who receives medical assistance and become incarcerated is the effective date on the decision notice.
Denial. The effective date for denying benefits is the earlier of the following:
Converting from Standard/Plus Benefit Packages. Consider the following when converting a client from or to the Standard benefit package:
Premiums. The effective date is always the first of the month. The effective date for applying the OHP premium for a new certification period is the month following the budget month.
The effective date for changing the amount of a premium per rule 461-135-1120 is:
Eligibility Following Closure. If the client completes the application process within the time period described in section B.1, The effective date is determined as follows:
Reimbursement of employer-sponsored health insurance premiums. The effective date for starting reimbursement of cost-effective employer-sponsored health insurance premiums per rule 461-135-0990 is one of the following:
For more information on cost-effective, employer-sponsored insurance, see GPE Section F.
Restored benefits. The effective date for restoring benefits that were denied or closed in error is one of the following:
Reductions Pending a Hearing Decision. When a reduction in benefits is delayed because the client requests a hearing, and the final order dismisses the hearing or upholds the Department’s decision, the effective date for ineligibility or reducing benefits is the first day of the month following the issuance of the final order.