OBSOLETE POLICY CHIP MANUAL |
Effective: March 17, 2021 - February 28, 2022
Reviews Not Requiring Client Participation (Ex Parte)
Ex parte reviews will be conducted for CHIP cases, whenever possible. However, do not conduct an ex parte review for CHIP in the following situations, as they require client participation in the review process.
The household has self-employment income; or
The household has rental income; or
The client is no longer eligible for CHIP.
Use current electronic data sources and case information to complete the review.
Update changes in income using current electronic data sources.
If income verification is incomplete or there is not at least one full quarter of wages to complete a good best estimate, an ex parte review cannot be completed.
The only exception is if the income has been verified within the last 6 months, such as using an employer statement or check stubs.
A best estimate of income can be completed on income not previously reported if there is enough information to complete a good best estimate Refer overpayments if applicable. (See Section 806-1)
Do not change or remove income that cannot be verified by an electronic data source if the income has already been verified by the agency through another source, and it is not questionable.
This includes such things as alimony, cash contributions and pension payments.
If CHIP assistance can be renewed using electronic data sources and case information, update eligibility, set a new certification period and send a notice of decision.
This includes moving a client from one CHIP plan to another.
The new certification period begins the month after the review month.
Client participation is required in the review process if there are questionable items as listed below in 5, in which case, the agency cannot complete an ex parte review and must conduct a review requiring client participation.
A new certification period can be set for other medical programs with future review dates if all factors of eligibility have been reviewed, with the following exceptions:
A time limited program which is set to end before the next review; or
Situations where an ex parte review cannot be completed because client participation is required.
If there are questionable items that need to be verified, do not complete an ex parte review; client participation in the review process is required. Client participation in the review process is required when, but is not limited to:
A data match finds income that has not been previously reported and there is not enough information to complete a good best estimate of income, such as not having a full quarter of wages;
An income change causes an individual to be ineligible for ongoing CHIP coverage.
If the changes would move an individual from CHIP to another medical program, the client will be required to complete the regular review process.
When processing an ex parte review, do not require verification of access to affordable health insurance to complete the review.
If access to employer sponsored health insurance has not been verified or the agency is questioning access to affordable health insurance:
Complete the ex parte determination, update eligibility, set a new certification period, then send a notice requesting verification of access to affordable health insurance.
Give the client at least 10 days from the date of the notice to return the verification.
For changes reported after the ex parte review is completed see section 804 & 102-3 to determine what action to take.
Reviews Requiring Client Participation
Send the client a pre-populated review form with the most current information from electronic records. The review form will explain what the client is required to do to complete the review process and the due date for responding.
A signature is required.
If the client responds by the due date, or sometime during the review month, request needed verification from the client. The agency must send a written request and give the client at least 10 days to provide the verification.
If the client does not return all requested verification by the due date, eligibility ends at the end of the month for which the eligibility agency can give 10-day notice.
The client has three months after the effective closure date to complete the review without having to re-apply.
If the agency cannot give 10-day notice before deciding eligibility for a new enrollment period, extend benefits to the following month. This is called the “due process month”. (See Section 803 for exceptions to 10-day advanced notice.)
Benefits cannot be extended during the eligibility review for a CHIP eligible child who turns age 19 in the review month.
If the client provides all the requested verifications by the verification due date, the eligibility agency proceeds with the eligibility decision.
The agency continues eligibility into the following month (the “due process month”) if needed while it makes a decision.
Do not end or adversely change eligibility until the end of the month for which the eligibility agency can give a 10-day notice. This includes changing CHIP plans from B to C.
If the client provides all requested verification after the due date and before the end of the review month, proceed with the eligibility decision.
The agency continues eligibility into the following month (the “due process month”), if needed, while it makes a decision.
Do not end or adversely change eligibility until the end of the month for which the eligibility agency can give 10-day notice.
If eligibility is continued into the “due process month”, the client must provide verification by the verification due date.
If the client provides verification by the due date, complete the review and send the notice of the eligibility decision. Do not end or adversely change eligibility until the end of the month for which the eligibility agency can give 10-day notice.
If the client fails to provide verification by the due date, close the case and send notice.
If an overpayment investigation determines individuals were not eligible in the review month and a due process month was established, the referral must include the due process month. (See Section 806-2)
For changes reported after the review requiring client participation is completed, see sect 804 and 102-3 to determine what action to take.
Client fails to complete review process
If the case closes because the client fails to complete the review:
Eligibility ends at the end of the month in which proper notice can be sent.
Client has three months following the closure date to complete the review without submitting a new application.
If eligibility is extended to the month after the review month, the three month period begins after the second month.
The benefit effective date is the first day of the month in which the client contacts the eligibility agency.
There is no retroactive benefit.
The client may request coverage for the 4-day grace period. (See Section 701-2)
An interview or application form is not required
Eligibility does not continue while the agency makes a decision.
Application processing time applies.
If the client provided updated TPL information during the failed review period, do not request it again to complete the review.
If the client fails to respond within the three months after the case closes for failure to complete the review, require a new application.