Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 101 - Coverage Groups and Processing Applications and Reviews Redetermination Processes › Chapter 12 - The Redetermination or Renewal Process › Rule 23-101-12.6 - Exparte Reviews

Current through June 25, 2024
A. Any individual
				or beneficiary under review who is losing eligibility in one (1) category of
				eligibility is entitled to have eligibility reviewed and evaluated under all
				available coverage groups.
B. The
				term "exparte review" is defined as to review information available to the
				Division of Medicaid to make a determination of eligibility in another coverage
				group without requiring the individual or beneficiary to come into the regional
				office or file a separate application.
1. For
				an exparte determination to be made, the Division of Medicaid must be in the
				process of making a decision on a current application, review or reported
				change. If the Division of Medicaid is denying or closing the case for failure
				to return information or failure to complete the interview process, an exparte
				determination is not applicable.
2.
				The decision of whether the individual or beneficiary is eligible under a
				different coverage group must be based on information contained in the case
				record which may include:
a) Income,
				household or personal information in the physical record which indicates the
				ineligible adult or child has potential eligibility in another coverage group
				and/or
b) Information received
				through electronic matches with other state or federal agencies such as a
				disability onset date or prior receipt of benefits based on
				disability.
3. When
				potential eligibility under another coverage group is indicated, but the
				Division of Medicaid does not have sufficient information to make an
				eligibility determination, the individual or beneficiary must be allowed a
				reasonable opportunity to provide the necessary information.
4. If the individual or beneficiary is
				subsequently determined to be eligible in the new category, the approval is
				coordinated with termination in the current program to ensure there is no lapse
				or duplication in coverage.
a) If requested
				information is not provided or if the information clearly shows that the
				individual or beneficiary is not eligible under another category, eligibility
				in the current program will be terminated with advance notice.
b) During the advance notice period, the
				individual or beneficiary is allowed time to provide all requested information
				to determine eligibility in the new program, provide information which alters
				the decision to terminate benefits in the current program or request a Fair
				Hearing with continued benefits.
5. If the individual or beneficiary
				subsequently provides all of the information needed to assess eligibility in
				the new program within ninety (90) days from the effective date of termination
				for modified adjusted gross income (MAGI) or aged, blind and disabled (ABD)
				closurest, the case is handled in accordance with the redetermination
				reinstatement procedures. A new application is not required.