Continuous Eligibility Periods 510-05-53-15

(Revised 7/1/14 ML #3406)

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Continuous eligibility may be established from the first day of the application month, or if later, the first day that the individual becomes eligible for Medicaid under a coverage group other than medically needy. Continuous eligibility periods cannot be established when re-working a prior month

Example 1: A child applies for Medicaid on June 8 and is determined to be categorically needy eligible. The child becomes continuously eligible effective June 1.

When retroactive eligibility is approved for an applicant, 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 with a disabled child applies for Medicaid on October 9 and requests Medicaid for the three prior months. The application is processed and it is determined that the child is categorically eligible for October, and for the three prior months. The child becomes continuously eligible effective October 1 regardless of their coverage group status during the three prior months.

Except as identified in subsection 5, 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.