701-5 Eligibility Decisions

Effective Date: July 1, 2024

Previous Policy

A. Deadline for determining eligibility

1. The eligibility worker must make an eligibility decision within 30 days of the date of the application. In the case of an application received through the FFM, make the decision within 30 days from the date the individual’s electronic account was received. Determine eligibility for MAGI programs first, including CHIP, before looking at non-MAGI or medically needy programs.

a. Applicants may request more time to provide verifications before the end of the application period.

b. If you cannot make an eligibility decision by the deadline, document the cause of the delay.

2. If unverified eligibility factors do not affect the eligibility of the entire household, approve the application for those household members determined eligible. For example, the individual has not given proof of alien status for one child. Do not approve the application if unverified eligibility factors affect the whole household. (For example, the wages of a working parent are unverified.)

a. Take steps to obtain the unverified eligibility factors.

b. If the applicant does not respond to the requests by the deadline, or by the end of the processing time, whichever is longer, deny the application.

3. If the applicant asks for more time to provide verifications before the end of the application processing time, OR the agency asks for more information, give the individual at least 10 more days to provide the verifications, extending the application time as needed to give the individual time to return verifications.

4. When verifications are received that show the applicant is ineligible, deny the case.

a. You do not have to wait until the end of the 30- day period to send the denial notice when you have proof the individual is not eligible.

b. Do not deny the application before the end of the 30-day processing period if verifications have not been received. Instead, wait until the end of the application processing time before denying for lack of verifications.

5. If the applicant returns verifications within 30 days after an application has been denied, use the date the verifications are received as a new application date.

a. The individual does not have to complete a new application form; however, document the new application date.

b. Determine the CHIP grace period based on the new application date if the child has a medical need. (See Sec. 701-2 )

B. Withdrawal of an Application

1. An applicant may withdraw an application for any reason at any time prior to a decision being made on the application.

2. Encourage the applicant to write a statement to withdraw the application.

3. If the applicant does not write a statement, document the request in the case notes.

4. Properly deny the application and send a denial letter to the applicant stating that the reason for the denial is that they withdrew the application.

C. Documentation of Decision

Document the eligibility decision.

1. If the application is denied, note the date and the reason for the denial.

2. If the application is approved, indicate the date and the medical assistance programs approved for the various household members. If some members are approved and others denied, clearly narrate this.

D. Notification of Approval or Denial

When the application is approved or denied, notify the applicant in writing of the approval or denial. If different decisions are made for different household members, address each decision in the notice or notices.

1. If the application is denied, state the reason for the action and give the policy citation for the denial reason.

2. Tell the individual where to call if the individual has questions or concerns.

E. Transferring an Electronic Account to the FFM

Individual information will be transferred to the FFM if the application is denied.