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MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |513 Effective Month: December 2016 EXPARTE REVIEWS (Continued) Using DOM-307, the specialist will ask the recipient to provide verifications needed to determine eligibility in the new category. If the individual is an ABD recipient potentially eligible in an MAGI category or vice versa, the request will include completion of the appropriate application form to collect required program information. An in-person interview is not conducted in the exparte review process even for a program that normally requires an interview.

Eligibility Decision If the individual is subsequently determined to be eligible in the new category, the approval must be coordinated with termination in the current program to ensure there is no lapse or duplication in coverage. However, if requested information is not provided or if the information clearly shows that the recipient is not eligible under another category, eligibility in the current program will be terminated with advance notice.

During the advance notice period, the recipient is allowed time to provide all requested information to determine eligibility in the new program, provide information which alters the decision to terminate benefits in the current program or request a hearing with continued benefits. The specialist must take prompt and appropriate action to reinstate benefits when the recipient either provides all requested information needed to determine eligibility in another category, provides information which changes the termination decision in the current program, or requests a hearing with continued benefits during the advance notice period.

NOTE: When the recipient is determined ineligible in the new category, he does not have to repay the benefits he received while the eligibility determination was in process. However, if benefits are continued pending a fair hearing decision and the outcome is not favorable to the recipient, he is liable for repayment of the cost of services furnished solely because of the continuation of benefit provision.

Requested Information Provided After Closure If the recipient subsequently provides all of the information needed to assess eligibility in the new program within 90-days of termination, the case should be handled in accordance with “Requested Information Provided After Closure,” described in 101.16.12.