Continuous Eligibility Periods 510-03-53-15

(Revised 5/1/2017 ML #3498)

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Continuous eligibility may be established from the first day of: The application month; or The month after the application month in which the individual becomes eligible for Medicaid under a coverage group other than medically needy.

When eligibility is being determined for one of the three prior months or when any other retroactive eligibility is approved, the continuous eligibility period DOES NOT begin during any of the retroactive months. An individual may be Medicaid eligible during the retroactive months; however, their eligibility is based on their actual circumstances during those months. Example : A family applies for Medicaid on May 8 and requests coverage for the THMP period of February, March and April. When processing the application month and THMP months, the child is determined eligible as an ACA Child in February and March, Medically Needy with a ‘spend down’ in April and as an ACA child in May. The child becomes continuously eligible effective May 1.

Except as identified in subsection 4, once an individual becomes continuously eligible, they remain eligible for Medicaid without regard to changes in circumstances, until they have been on Medicaid for 12 consecutive months. They do not have to have been continuously eligible for the entire 12 months.

When a review of eligibility is completed an eligible individual may be determined to be eligible for a new continuous eligibility period.

Reviews must be completed at least annually, but may be scheduled earlier in order to align continuous eligibility periods within a case between children, or to align review dates with other programs.

If the individual’s previous continuous eligibility period ended, the individual must meet all eligibility criteria to continue eligible for Medicaid. If a review is being completed before the individual’s continuous eligibility period has ended, and the individual meets all Medicaid eligibility criteria, the individual begins a new continuous eligibility period. If a review is being completed before the individual’s continuous eligibility period has ended, and the individual fails to meet all Medicaid eligibility criteria, the individual remains eligible only until the end of their current continuous eligibility period. A new review of eligibility is required at that time to establish any further eligibility.

A continuous eligibility period must be ended earlier than when the review is due for any of the following reasons: The recipient turns age 19; The recipient loses state residency; The recipient requests that their coverage end; The recipient dies; The agency has lost contact with the family and the child's whereabouts are unknown; or The recipient has failed to provide verification of citizenship or identity within their reasonable opportunity period.

A continuous eligibility period must also be ended if it is determined that the recipient should not have become continuously eligible because the individual was approved in error; approval was based on fraudulent information; an appealed ending is upheld in favor of the agency.