9300 Reviews

 

All categories of assistance require periodic review. At the expiration of the review period, entitlement of benefits to assistance ends. Further eligibility must be determined through the review process.  A formal review is not required to retain coverage under the SSI program. Depending on the type of assistance received and the household circumstances, the review may be either passive or non-passive.  A non-passive review is based on a review application or form and any required verification  

 

9310 Review Process - The review process is a complete re-examination by the agency concerning all factors of eligibility.   In the process, the appropriate review form shall be used along with information available through specified interfaces and rest of the agency record (except for review extensions per 9310.1 where a form is not required). The purpose of the review is to give the client an opportunity to bring to the attention of the agency his or her needs and to give the agency an opportunity to re-examine all factors of eligibility in order to determine the household's continuing eligibility for assistance.

 

9310.1 Review Extension  - A review extension is a review of eligibility without a formal application. An extension may be completed prior to the expiration of the current period in the following situations:

 

  1. moving from QMB to LMB or vice versa;
     

  2. moving from Medicaid (including Medically Needy) to QMB or LMB; or
     

  3. at the end of the regularly scheduled TB review for TB.
     

Except for TB cases, contact with the beneficiary is required to confirm current financial and non-financial factors prior to completing the extension review. The contact may be in person, phone or in writing. Failure to respond to the request will not result in negative action unless the request addresses other eligibility factors. The current review period remains in place. The prudent person concept (see 1310) applies for verification issues. A new application is required for regularly scheduled reviews and when required per KEESM 1410 and subsections.

 

A new 12 month review, or 6 months for TB cases, is established upon completion of the review extension.

 

9310.2 Passive Reviews  - In addition to the traditional non-passive review process using a paper review form described in 9310.3, the medical programs, based on select criteria, may be reviewed on either a passive or super-passive basis.


  1. Super-passive review – A super-passive review is a review where the medical program is automatically re-evaluated based on program type as well as the income, resources and household circumstances known to the agency or obtained by the agency as part of the review process.   If eligibility continues under the Super Passive criteria, a new 12 month review period is established with notification to the household.    Medical assistance cases eligible for a Super Passive review are:

 

a.  Medicare Savings Programs for SSI recipients

 

b.   Medicare Savings Programs for persons with no income and  countable resources less than $2000

 

      c.    Medicare Savings Programs for persons with no income other than Social Security and resources less than $2000

 

Note:  For two person households, both individuals must meet the above criteria.

 

     2.  Passive review - A passive review is where the medical program is automatically re-evaluated based on program type, income, resources and household circumstances to determine continued eligibility using the information already known or obtained by the agency.  If eligibility continues under the Passive review criteria, a new 12 month review period is established with notification to the household.  In addition, a separate notice identifying the information used by the agency to make the eligibility determination is issued, with instructions to contact the agency if any of the information needs to be updated or corrected.  Contact with the agency is not required if there are no changes or corrections to report.   If changes are reported, either orally or in writing, action is taken to update the case.    

 

         Medical assistance cases eligible for a Passive Review are:

 

a. Protected Medical Groups  (Pickle, Adult Disabled Children  and EDW) without self-employment or earned income if countable resources are less than 85% of the applicable resource limit and there is no trust.

 

b.  Medically Needy: without self-employment or earned income if countable resources are less than 85% of the applicable resource limit and there is no trust.. Cases with due and owing expenses allowed against the spenddown are not eligible for Passive Review.

 

      c.    Medicare Savings Programs.  Cases that fail the Super-Passive criteria above without self-employment or earned income if countable resources are less than 85% of the applicable resource limit and there is no trust.

 

               d.    Long Term Care Programs (NF, HCBS, MFP, PACE) without self-employment or earned income if countable resources are less than 85% of the applicable resource limit and there is no trust. Cases with due and owing expenses allowed against the spenddown are not eligible for Passive Review. Cases impacted by Spousal Impoverishment are not eligible for passive review.

               

    3.  Passive Review Responses: Following a Passive Review, the household is required to contact the agency (either orally or in writing) if any of the information   included in the Passive Review needs to be changed or updated.  Treatment of the change depends on when the change occurred, when it was reported, and type of eligibility received.

 

             a.    If the change occurred on or before the 15th of the last month of the old review period, the change is processed as a Passive Review Response.

 

             b.    If the change occurred after the 15th of the last month of the old review period, the change is not considered a passive review response.  It is treated like any other change reported outside of the review period.      

 

 To process the Passive Review Response, staff shall update the case with changes and re-determine eligibility for the first unpaid month.  Any changes in coverage or cost sharing are subject to timely and adequate notice requirements.  

 

 

 9310.3 Pre-Populated Reviews:

 

     During the automated re-evaluation of eligibility, it may be determined that a passive or super-passive review is not appropriate.  In that case, the individual will  be required to complete a formal review form/application.  A pre-populated review is sent to the household with information contained within the KEES system.  A notice of expiration of the review period (see 9320) is included with the Pre-Populated form. 

 

     Households must update the form with new or changed information and return it to the agency.

 

1.    Failure to return a completed form by the due date (see 9331) will result in discontinuance of coverage.   

 

2.    For households who do not return the review by the end of their review period, the review form can be used to determine eligibility if the form is returned by the last day of the third month following the end of the review period. 


 

 

9320 Notice of Expiration - A notice of expiration of the review period shall be sent to each household. The local agency shall provide an application form with the notice of expiration. When a review must be made and it is known that the recipient is temporarily visiting away from his or her residence, the notice of expiration and appropriate form should be mailed to the temporary address.

 

In all programs, except those passively or super-passively reviewed, a notice of expiration shall be mailed to the household no earlier than the first day of the next-to-the-last month of the review period and no later than the first day of the last month of the current review period.