REISSUED 08/01/13 – CHANGE NO. 05-13
Whenever an individual is determined ineligible for Medicaid in any aid program/category he must be evaluated for ongoing Medicaid eligibility. Complete an evaluation to determine if the individual is eligible for any other aid program/category before terminating any Medicaid coverage for the aged, blind or disabled. The evaluation is to include Medicaid for the Aged, Blind, and Disabled (MAABD), including HCWD, MQB-Q, MQB-B, MQB-E, Qualified Disabled Working Individuals, NC Health Choice and Family and Children's Medicaid. Refer to III. below for exceptions to this policy.
The term “ex parte review” means to review information available to the agency to make a determination of eligibility, without requiring the beneficiary to come into the agency or make a separate application. A signed redetermination document is not required for an "ex parte review." The county must explore and exhaust all possible avenues of eligibility in all Medicaid coverage groups as well as NC Health Choice for Children. If information is not available to make a determination of eligibility, the county must provide the beneficiary reasonable opportunity to provide the necessary information.
When reviewing ongoing Medicaid eligibility, if you establish eligibility in an aid program/category that requires the creation of a case in EIS, a signed application is not required. Enter the DSS-8124 as an administrative application or reapplication.
For example: MAD case is terminating due to no longer considered disabled. Evaluate the case for any other Medicaid coverage group, including HCWD Medically Improved Coverage, or NC Health Choice before terminating case. Client has a child in the home under 18 years old receiving Medicaid. Caseworker found the client is eligible for Medicaid for Families (MAF). The county should not require a signed application. Enter the DSS-8124 as a new administrative application.
Always send appropriate notice before termination.
REVISED 08/01/13 – CHANGE NO. 05-13
Refer to III below for the exceptions to continuing Medicaid when Medicaid, (both adult and family and children) including Work First, terminates.
When a individual is determined ineligible in a Medicaid only aid program/category, continue his authorization until he is determined eligible or ineligible for ongoing Medicaid in all other aid program/categories.
When the ex parte review or redetermination is completed and ongoing Medicaid eligibility is established, authorize the individual for the appropriate aid program/category. MAABD authorization requires an unsigned administrative new application if ineligibility was in a Family and Children's Medicaid aid program/category. Follow policy rules to determine the appropriate certification period.
Example: MAD case at redetermination is found to no longer meet the definition of disability and does not meet the eligibility requirements for HCWD. Individual is eligible for MAF as caretaker due to a child receiving Medicaid in the home. This requires an unsigned administrative new application.
For questions or clarification on any of the policy contained in these manuals, please contact your local county office.