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Example 3: On 07/25, an individual reports that their last day of work was 07/18 and the last paycheck will be received 07/26. The recipient provides a statement from the employer on 07/30 (within the 13-day guidelines). The earnings are removed from the budget effective 08/01 and any increase in benefits will take place in the 08/01 budget, even if the authorization occurs after adverse.

If the AG’s benefit level decreases, or the AG becomes ineligible because of the change, the decreases in the benefit level is effective according to the normal adverse processing guidelines. Using the same example as above, if the change was verified on 07/30, then a decrease in benefits would take place in the 09/01 budget.

See IHCPPM 4205.10.00 for information on Appealable Actions.

There are several exceptions to this, including the following:

• For individuals who become pregnant and are receiving coverage for Family Planning Services under MA E, if the individual reports that they are pregnant, eligibility for MAGP will need to be determined and coverage may be granted retroactively without requiring another application being filed. In such situations, the appropriate DFR staff member would need to create the new category with an override/fiat, if appropriate, to end date the MA E coverage so MAGP coverage could be granted.

• For an ongoing MA I recipient, if the member enters a nursing facility or is approved for a waiver, a review of the retroactive MA months should be completed to verify if the recipient is eligible for a full coverage category. After a thorough review of both income and resources is completed, and it has been determined that the recipient is eligible for retro months, then the assigned DFR staff member would need to create the new category with an override/fiat, if appropriate, to end date the MA I coverage so the full coverage MA could be granted.

• Health insurance payments for members residing in nursing facilities will be applied the month after it is processed by the DFR. Health insurance coverage begins after the member enrolls and the first payment is made; it does not begin prior to the first payment. If the member has verification that payments were made (such as a bank statement), this should be submitted to PAL for review for a possible deviation. These will be reviewed on a case-by-case basis; there is no guarantee of the deduction being applied retroactively.

If an ongoing HIP AG is determined eligible for a MED 1 or MED 4 category, then change processing guidelines must be followed. If the category change is processed after adverse, but before the end of the month, then please create the new category with an override/fiat to remove the ongoing months of coverage. Retro months cannot be removed.