South carolina department of health and human services medicaid policy and procedures manual

101.09.03 Application Actions (Rev. 04/01/07)

All applications will be subject to one of the following actions:

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  Approval – When all of the eligibility criteria are met, the application is approved.
  
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  Denial – When one or more eligibility criteria are NOT met, the application is denied. Death is not an appropriate reason to deny an application. If the applicant dies before a final eligibility determination is made, the application process must be continued to completion. An application for TEFRA, Nursing Home, or HCBS that requires both a level of care and disability determination cannot be denied by the eligibility worker until both decisions have been received.
  
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  Withdrawal – An application is considered withdrawn when the applicant indicates in writing his intent not to continue with the eligibility process.
  

101.09.04 Effective Date of Eligibility/Accrual Rights (Eff. 10/01/05)

In most cases, eligibility begins with the month of application. (Refer to individual program chapters for rules applicable to specific categories.)

101.09.05 Case Actions (Eff. 10/01/05)

All active cases will be subject to one of the following actions:

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  Review – (Refer to MPPM 101.11.)
  
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  Closure/Termination - When the beneficiary no longer meets the eligibility criteria, the beneficiary’s eligibility is terminated and/or the case is closed, if appropriate. This action may also be taken if the beneficiary requests to have the case closed.
  

101.09.06 Exparte Determinations (Eff. 10/01/13)

When Medicaid eligibility for an applicant/beneficiary is denied or terminated under one coverage group, the Medicaid eligibility worker must determine whether each applicant/ beneficiary applying for or receiving coverage is eligible under any other coverage group. This determination is called an exparte determination. An exparte determination is a Medicaid eligibility decision using information that is readily available to the eligibility worker with minimal contact with the applicant/beneficiary. If during the process it is determined a beneficiary may be eligible for Medicaid, but additional information is required to make a final determination, the beneficiary will remain eligible in the original category while the worker secures the documentation needed to make the determination for the new category. If it is decided that the beneficiary is not eligible for the new category, the beneficiary does not have to repay benefits received during this period.

Examples of readily available information used to complete an exparte determination include case record documentation and system interface information. Information in an ACTIVE case is considered accurate if the worker has no reason to believe otherwise. Information in an INACTIVE case can be relied upon if the information was obtained within one year and the worker has no reason to doubt its accuracy.

1. 
   Readily available information must be reviewed to find out if each beneficiary receiving or applying for Medicaid is potentially eligible under any other program. The last application must be reviewed to see if the applicant/beneficiary may be eligible in another category. Check SDX, BENDEX, and the latest application or review to find out if any beneficiary is receiving or has received disability or claims to be disabled. For specific procedures for Deemed Babies, refer to MPPM 203.03.02.
   

2. 
   After reviewing the available information:
   

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  If the applicant/beneficiary is eligible in a different payment category, approve the case in the new category.
  
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  If the applicant/beneficiary is not eligible in any other payment category, deny/ terminate the original payment category using the original denial/termination reason.
  
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  If the applicant/beneficiary appears potentially eligible based on the case record, but all information is not available to make the decision, contact the applicant/ beneficiary for the required information. The DHHS Form 1233-E, Medicaid Eligibility Exparte Checklist, must be sent to the beneficiary requesting the information necessary to make a final determination on the case. The beneficiary will be given 10 days to provide this information. The 10 days begin on the date the DHHS Form 1233-E is sent.
  
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    For current beneficiaries, continue the eligibility in the existing category. If the case is currently due for review, the eligibility worker must enter the Form Received Date in MEDS on the WKR008 (Regular Review) screen to avoid a system closure. Make Decision can be made at this time, but the eligibility worker must not call Act on Decision. The Anticipated Closure Date (ACD) must be set to 90 days in the future and the Next Review Date (NRD) must be set for 12 months. Do not create a new budget group for the alleged payment category. If the beneficiary returns all required information within 10 days, the eligibility worker will proceed with making the eligibility determination. If the beneficiary is eligible under the alleged payment category, exparte to the new payment category. From the date of decision, for FI related payment categories, set the NRD to one year; for SSI- related categories, set the NRD to one year in the new budget group. If the beneficiary is determined ineligible for the alleged payment category, the worker must close out the existing budget group using the original denial/termination reason code. The ACD must be removed and the system may prompt you to Make Decision (to update the eligibility end date) before continuing with Act on Decision.
    
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    If the requested information is not returned within 10 days, the eligibility worker must proceed with closing the case. If at any point ineligibility is determined, coverage can be denied or terminated. It is not necessary that all eligibility criteria be verified before denial or closure can take place. Exception: If the potential category is TEFRA, Nursing Home, or HCBS, both a level of care and disability determination decision must be made before the application is denied.
    

3. 
   If a disability decision is required in the potential category, refer to MPPM 102.06.02A for the blindness/disability determination process.
   

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  If an applicant/beneficiary indicates disability, but describes a condition that would realistically not be considered disabling, such as she admits to only having high blood pressure that is under control with medication but no other problems, then this individual would not be considered disabled. Also if there is a recent Social Security denial for disability and there is no allegation of a change in his condition, an independent determination is not necessary. If there is any reasonable doubt, the eligibility worker should complete a disability determination. Regardless of the applicant/beneficiary’s medical condition, if he insists on a disability determination, one must be completed.
  

3. 
   If a beneficiary receives a closure notice (that is, was Medicaid eligible and the case is going to close or has been closed) and requests a continuation of coverage within 30 days from the date on the closure notice and appears potentially eligible based on the alleged categorical requirements, coverage must be re-instated in the original category. The DHHS Form 1233-E must be sent to the beneficiary requesting the information necessary to make a final determination on the case. The beneficiary will be given 10 days to provide this information. The 10 days begin on the date the DHHS Form 1233-E is sent.
   

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  If a disability decision is required in the potential category, refer to MPPM 102.06.02A for the disability/blindness process. When the information is received, the worker will proceed with making a final determination on the case.
  
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  If the beneficiary requests coverage to continue but does not indicate any reason that falls under a potential category, this must be documented in the record, and the process for termination continues.
  

3. 
   If an applicant receives a denial notice (that is, has not been approved for Medicaid and the application has been denied in MEDS) and requests reconsideration for another category within 30 days from the date on the notice and appears potentially eligible based on the alleged categorical requirements, the original application date can be used. Pend the application in MEDS using the potential category. The DHHS Form 1233-E must be sent to the applicant requesting the information necessary to make a final determination on the case. The applicant will be given 10 days to provide this information. The 10 days begin on the date the DHHS Form 1233-E is sent.
   

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  If a disability decision is required in the potential category, refer to MPPM 102.06.02A for the disability/blindness process. When the information is received, the worker will proceed with making a final determination on the case.
  
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  After making the final determination for the potential category, approve or deny the application in MEDS using the appropriate reason.
  
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  The case cannot be exparted if the request is received after 30 days. If the request is made after 30 days, a new application is required.
  

3. 
   For Pregnant Women cases, once the 60-day post partum period ends, the eligibility worker must determine if the beneficiary is eligible for Medicaid under any other coverage group with full benefits (ex. LIF, PHC). If the beneficiary is not eligible for a full benefit category then the eligibility worker must consider eligibility for Family Planning.
   
4. 
   Minor applicants/beneficiaries cannot be ex parted from any Medicaid category to Family Planning unless requested by a parent or legal guardian or by the minor. An adult of child bearing age who applies for or receives Medicaid benefits can be considered for all Medicaid categories for which eligibility can be established, including Family Planning and for eligibility for other affordability insurance programs through the Federally Facilitated Marketplace.