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 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): There is no self-employment or earned income, countable resources are less than 85% of the applicable resource limit, and there is no trust.
b. Medically Needy: There is no self-employment or earned income, countable resources are less than 85% of the applicable resource limit, there is no trust, and there are no due and owing medical expenses allowed, and the status of the spenddown is ‘met’.
c. Medicare Savings Programs: Cases that fail the Super-Passive criteria above without self-employment or earned income, countable resources are less than 85% of the applicable resource limit, and there is no trust.
d. Long Term Care Programs (NF, HCBS, PACE): There is no self-employment or earned income, countable resources are less than 85% of the applicable resource limit, there is no trust, and there are no due and owing medical expenses. LTC programs 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 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.
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.
9310.4 Using an Application Form as a Review – An application form shall be used as a review in the following circumstances:
1. An application form received within two months prior to the month the review is due shall be considered a valid review provided the first month of the new review period is available (come-up month) at the time the application is processed the first month of the new review period is not available at the time the application is processed, the consumer must comply with the normal review process.
2. An application form received in any month after the month the review is due through the current month when the Review Discontinuance Batch has not been run. When eligibility has not been discontinued at the end of the month the review is due, the review will be processed for the come-up month in KEES. The come-up month will be the first month of the new review period.
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.
9320 Notice of Expiration - A notice of 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 (9310.2) or super-passively (9310.1) 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 notice of expiration and pre-populated review form shall be mailed to the household on or about the 15th of the next to last month of the review period. This gives the household approximately 30 days to complete and return the review form to the agency (see 9331).
NOTE: The notice of expiration provides timely notice of the ending of benefits; therefore, further timely notice is not required to affect benefits for the start of the new review period.