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.
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.
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:
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 1410 and subsections.
A new 12-month review, or 6-months for TB cases, is established upon completion of the review extension.
In addition to the traditional non-passive review process using a paper review form described in 9310.3, the medical programs may be reviewed passively based on select criteria.
If a person qualifies for a passive review but is in the same household with members with a pre-populated review type, or if the data used at passive review will result in coverage on a lesser program, a pre-populated form will be sent to give them the opportunity to report changes. If the form is not returned, the members with the passive type will be approved using the information in the system. If it is identified that an individual received a pre-populated review in error because a citizenship record changed to an unverified status after it had already been verified, or because a pending record exists (e.g., a missing or unverified SSN), the pre-populated form is not required. They may be reinstated if necessary and administratively reviewed and approved using the information on file.
To qualify for a passive review when there is earned income, the income must be reasonably compatible (RC) under the automated RC test completed by KEES. Additionally, individuals may qualify for a passive review when no data is returned via income interfaces (KDOL/TALX) and the countable income on file for the assistance plan is under 100% of the Federal Poverty Level (FPL). This option is available for up to five (5) consecutive years. After that, a new income attestation is required, usually through the pre-populated review process. However, if an updated attestation is voluntarily submitted before the five (5) year limit, the five year (5) timeframe resets.
When unearned, countable income from Social Security (SSA) exists, it must be within $5.00 of the amount found on the SSA data source.
Individuals with stable income sources may also qualify for passive reviews. Stable income is income that is known to be highly unlikely to change or decrease in value. For non-MAGI coverage, stable income sources include:
In addition, each of the following program types may be subject to a passive review when specific criteria are met:
NOTE: Cases in which the primary applicant (case head) is coded deceased or permanently out of the home are not eligible for passive review. In these situations, the case is excluded from the review determination batch and a pre-populated review is issued.
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.
During the automated re-evaluation of eligibility, it may be determined that a passive review is not appropriate for the case situation. In these instances, 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.
An application form shall be used as a review in the following circumstances:
All household members must be listed on the application in order to use the application to complete a review. If all household members are listed, the application is used to complete the review. The application must be reviewed for consistency with the known case information. If additional information is needed to process the review, it shall be requested of the consumer, but another application form or review form is not required.
It is not necessary for the applicant to have requested coverage for all household members on the application. If the individuals who are due for review are listed on the application form, it is assumed that they wish for coverage to continue, and the form shall be used as a review for them. If the form does not include all household members, it shall be used to determine eligibility for the newly requested individual. If the Review Due date is in the past, manual action shall be taken to discontinue the remaining household members for failing to return their review.
A review form including the expiration of the review period shall be sent to each household subject to a pre-populated review as described in 9310.3. A notice of expiration of review is not required for passively reviewed households. The agency shall provide a pre-populated review form with the notice of expiration. When a review is required and it is known that the recipient is temporarily visiting away from his or her residence, the notice of expiration and review form should be mailed to the temporary address.
The pre-populated review form shall be mailed to the household when the Medical Reviews Batch runs, on or about the 15th of the month, two months prior to the end of the review period. (e.g., for a December review, the form will be mailed in mid-October). This gives the household approximately 60 days to complete and return the review form to the agency (see 9331).
NOTE: The timeframe to submit the form includes timely notice for discontinuance of benefits; therefore, further timely notice is not required to affect benefits for the start of the new review period.
As indicated in 9320, individuals subject to a pre-populated review shall be given a minimum of 60 days to return a required review form. The review form shall be mailed to the individual on or about the 15th two months prior to the end of the review period. To be considered timely received, the signed review form (see 1411.5 (1)) must be returned to the agency by the last day of the last month of the review period. Reviews received outside this period will be considered late. If the review form is not received by the time the discontinuance batch runs (around the 15th of the last month of the review period), coverage will be automatically discontinued with an effective date of the last day of the last month of the review period. See 9350.
When a review form is received by the last day of the review month, this is considered timely. Eligibility at current levels will continue automatically until the review process is completed. Otherwise, the review discontinuance batch will close the individual by the last day of the review month. For reviews received during the reconsideration period, coverage will not be rescinded, and the effective date will follow application policies (see 9350).
Note that if a review is received before the last day of the review month but was closed by the review discontinuance batch in error, the discontinuance shall be rescinded and coverage shall be reinstated pending the completion of the review.
Due to this process, if a review received on or before the last day of the last month of the review period is not timely processed by the agency, as defined in 9340, the current level of coverage for the individual(s) due for review may continue past the end of the review period for one or more months [extended month(s)]. The date the timely review is received, and new program eligibility will determine if those months are subject to correction.
NOTE: If the review is not timely processed, as noted above, eligibility will continue at the current level until some intervening action, automated or manual, is taken to either change or discontinue coverage. If the ultimate action taken on the case is adverse, timely and adequate notice of the action is required. See 1431.
All information and/or verification shall be provided by the requested date. Clients must submit any required verification or additional information within 12-days from the date of the initial request in order to ensure the rights to uninterrupted benefits, provided the deadline to submit such verification does not occur prior to the date the application was timely filed.
For information received during the review reconsideration period, see 9350.
Follow the verification requirements at initial application, 1322, except that citizenship, non-citizen status, providing an SSN, residency, and identity, do not have to be reverified unless a change has been reported or it is questionable.
If the above conditions have not been met, all resources must be reverified. The standard verification process for an initial application applies. Except, verification of bank accounts [excluding Direct Express accounts – see 1322(9)(c)] for pre-populated reviews that fail to meet the policy requirements described above shall be requested through the electronic Asset Verification Solution (AVS). The agency must allow ten (10) days for the AVS results to be received. If a response is not received timely, then verification of the bank account(s) shall be formally requested from the recipient. If the AVS response verifies the bank account (even after formally requesting verification from the individual if the response was not received timely), that amount shall be budgeted on the case. Otherwise, the verification received from the recipient based on the agency request shall be used.
NOTE: When applying the 85% countable resource threshold, income known to be deposited into a countable financial account shall first be deducted from that account in determining the countable resource value. Income shall not be deducted from the balance provided on an AVS response, unless it is the specified interest income noted on the AVS response.
If the review form is timely filed and all review requirements have been met, the agency shall promptly process the review to ensure correct and timely coverage is provided. Timely processing shall be defined as follows:
NOTE: This process may result in an extended month of coverage. Any extended month of coverage provided under this process is subject to adjustment as indicated in 9332(2) if understated eligibility has occurred. However, in no instance shall a claim subject to recovery be created for the extended month [see 11122(2)].
All households shall be notified of the appropriate reporting requirements upon review approval. See 9120.
An individual who untimely submits a review form or timely submits a review form but submits all verification in an untimely manner shall lose the right to a prompt review of eligibility (see 9340). The agency shall determine eligibility for these individuals within 30 calendar days after the date the untimely verification is provided.
If the review form is not returned by the end of the current review period, the individual has a three-month reconsideration period to return the review form. Individuals will have until the end of the third month from the date of discontinuance to return the form for processing. The reconsideration period also applies to information requested in order to process the review. An application or review form received after that period is treated like a new application, including any request for prior medical assistance. If the requested information is provided after the reconsideration period expires, a new application may be required.
A review reconsideration period is not applicable to an individual who is approved at review or is denied at review for not meeting eligibility criteria. Any application for review not submitted in a timely manner shall be treated as an initial application. The timeliness provisions of 1413 apply. Prior Medical coverage must be requested for eligibility to be determined in any gap months. See 9350.2(a) and (b) below for program specific prior medical coverage requests.
The reconsideration period applies to information requested to complete the review. When an individual is discontinued at review for failure to provide requested information, they have three months to return the information without needing to submit a new application.
Prior medical coverage may be needed to fill any gap months, as indicated on the review form (per 9350), or when it is assumed necessary based on information received during the reconsideration period after a timely review form has been denied for failure to provide requested information. Coverage for prior months may be approved if otherwise eligible and if allowed by the program’s policy. Retroactive approvals are not permissible for all medical programs at application. Retroactive approvals during the review reconsideration period shall be processed in accordance with 7330 except as indicated below.
If the agency fails to timely process a timely received review form, an administrative processing error may have occurred. For reviews received before the discontinuance batch runs (around the 15th), eligibility will continue with coverage at the current level while the review is awaiting processing. This may result in one or more months of coverage past the end of the review period before the review is processed [extended month(s)]. Once the review is processed, the extended months of coverage resulting from the delay shall be reevaluated as follows:
For definition of timely processing of reviews see 9340.
All cases are to be periodically reviewed. The length of the review periods are noted below; however, all programs allow a review period for less than 12 months to be established when needed to match the review period on an existing program.
NOTE: An established review may be completed early in order to align a review in one program with the review in another program. Established review periods are not, however, to be shortened by notifying the household via a Notice of Eligibility Review, in order to align a review in one program with the review period for another program. In addition, if the household fails to comply with any aspects of the review for the other program, the program where the review is being done early shall not be negatively affected, other than acting on changes reported on the review form.
Reserved
Reserved
The specific medical program determines the length of the review period and whether a review is required.