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2220.15.00 FAILURE OF ASSISTANCE GROUP TO REPORT CHANGES

If the DFR discovers that the AG failed to report a change as required above and as a result received benefits to which it was not entitled, a referral is made to Benefit Recovery to initiate claim determination and benefit recovery.

2220.20.00 CHANGES REPORTED AND NOT VERIFIED TIMELY

When a member reports a change, which would increase their benefit or decrease their PAC/premium/liability, and it is reported but not verified by the 13th day, the benefits should continue at the current amount until after the untimely verifications are provided. If they are not provided, the benefit should be left at the previous level except for incarceration (refer to 2237.10.00).

For example: A member reports a decrease in countable income from a job that has already been verified. The worker then sends a 2032 giving the member 13 days to verify the new income. If the decrease in income is not verified within the 13 days, the worker should leave the income at the previous reported/verified amount and reauthorize the case. When the untimely verifications are provided, the change should be implemented from the date the verification was provided rather than the date the change was reported. Normal adverse/recur logic applies.

2220.25.00 PROCEDURES WHEN MEDICAID FACILITY LOSES CERTIFICATION

When a Medicaid-certified long term care facility receives notification from the Department of Health that its Medicaid provider agreement will be terminated, a copy of the notification is sent to the Local DFR Office. Generally, the facility is given 30 days advance notice of the loss of certification. However, the facility does have appeal rights. If the facility appeals and the Department of Health rules that the patients are not in immediate danger, the facility's Medicaid certification may be allowed to continue during a specified period while the deficiencies cited by the Department of Health are being remedied.

The DFR will need to stay in close communication with the facility concerning the facility's continuing Medicaid certification. Steps to change the recipients' data in IEDSS (Person Demographics – Details Page) should not be undertaken immediately by the worker upon receipt of the initial decertification letter. The facility's appeal status and any subsequent rulings of the Department of Health must be ascertained. If the worker cannot obtain the necessary documentation from the facility, the Central Office, Policy Answer Line, should be contacted.

2225.00.00 ADDING AN INDIVIDUAL TO THE AG (MED 2, MED 3)

Each Medicaid assistance group contains only one eligible person.