Complete a review of MO HealthNet eligibility every 12 months. Every review or change in circumstance requires appropriate action and recording.
Per 42 CFR 435.916(b), when information is received regarding changes in the individual’s circumstances (CIC) that may affect eligibility, a redetermination of eligibility for MO HealthNet must be completed.
When one or more changes occur, evaluate which eligibility factors may be in question to determine whether a complete reinvestigation is necessary or whether a review of certain eligibility factors will suffice. This may include: marriage, appointment of guardian, change in living arrangements, or change in income or resources.
Annual Reviews for MO HealthNet programs must be completed once every twelve months per 42 CFR 435.916.
A case must not be closed for failure to return a review form or complete an annual review, if continued eligibility can be established based on available information from other sources. An eligibility review is separate from the Medical Review Team (MRT) re-determination. As a result, eligibility reviews are to be completed by their due date and NOT delayed awaiting the MRT decision.
When available information indicates no change in eligibility, complete the annual review on the case without requesting anything from the individual.
EXAMPLE: Victor is covered underreceiving MO HealthNet Non Spend Down. A current review of the Work Number confirms Victor’s spouse’s income information. Victor and his spouse have no resources. There is no change in coverage and Victor remains eligible for MO HealthNet Non Spend Down. An Action Notice (FA-460) is sent notifying Victor there was no change to his coverage during the Annual Review process.
When completing a review, enter a new budget, income and resource documentation, and complete the eligibility determination. Add a comment in FAMIS on the income and resource screens showing how verified. Document how the annual review was completed, and add a comment documenting the new eligibility determination.
If the Annual Review cannot be completed because of insufficient information available to the agency, the MO HealthNet Eligibility Review form (FA-402) must be completed and returned by the participant.
NOTE: When an active MO HealthNet/Supplemental Nursing Care recipient changes to a vendor level of care or changes facilities, a review is not required to complete the action. Make the appropriate changes to the case and if a review is due, complete that as a separate action. Follow “MO HealthNet special instructions” in E-mail memorandum #42 Cancel Close Clarification and Instructions for FAMIS Cases when it is determined the case must be cancel closed.
Per 42 CFR 435.916(C)(ii), allow submission of the Annual Review Form (FA-402) up to 90 days after termination of eligibility.
The reconsideration period allows cases that closed for failure to return the (FA-402) to be reopened when the (FA-402) is received within 90 days from the date the closing action is completed in FAMIS.
NOTE: The 90 day reconsideration period is calculated from the date the case closes in FAMIS, and not the date MO HealthNet coverage ends.
Follow normal procedures when information or clarification is needed. When additional information is needed, send a Request for Information Notice (FA-325) to request the information or clarification.
The reconsideration period is treated in two different manners:
The certification period is extended for another 12 months.
If there is a lapse in coverage and the individual attests to unpaid medical bills, explore eligibility in the Prior Quarter (PQ) months; refer to 0810.015.00 Prior Quarter Coverage.
Note: If additional information is required, only request information needed to renew eligibility. Review and use current information in the case record and electronic data sources before requiring the individual to provide information for the Annual Review.
If the (FA-402) Annual Review form is received more than 90 days after the case closed, do not use the Annual Review form in place of an application. The individual must reapply through normal application procedures. Notify the individual how to reapply by sending the, Letter for (FA-402) Returned After 90-Days.
Federal Regulation 42 CFR 435.608 stipulates participants of MO HealthNet for the Aged, Blind, and Disabled (MHABD), Supplemental Nursing Care (SNC), and Supplemental Pension (SP), must take all necessary steps to obtain other benefits to which they are entitled receive unless the participant can show good cause for not doing so.
Other benefits include, but are not limited to, programs such as Qualified Medicare Beneficiary (QMB) and Specified Low Income Medicare Beneficiary (SLMB), OASDI, SSI, veteran’s compensation and pensions, railroad retirement, any annuities, unemployment compensation, and any other type of benefits the applicant/participant may be entitled to receive.
At reinvestigation, a participant must provide verification he/she has:
Unless the participant claims and can show good cause for refusal to apply for and accept other benefits, action must be taken to close the case when the participant either fails to provide verification of application, re-application, pending hearing/appeal, or refuses to apply.