704-1 Ex Parte Reviews (Reviews Not requiring Member Participation)

Effective Date: March 1, 2023

No Previous Policy

The eligibility agency must attempt an ex parte review on all CHIP programs. This is a redetermination of eligibility based on current, reliable information without the member participation.

A. Completing the Ex Parte Review

1. Use current electronic data sources and reliable case information to complete the review without contacting the member.

a. Determine if the electronic information can be used to update the case file (706).

b. Electronic income not previously reported may be verified if there is enough information to complete a best estimate.

· At least one full quarter of wages is needed to complete a new best estimate.

2. Any form of verification (705) may be used as long as it does not involve requesting information from the member, such as, electronic verification or collateral contact.

3. Do not change income that cannot be verified by an electronic data source if they are not questionable or have already been verified through another source within the last 6 months.

· This includes income such as alimony, cash contributions, or child support payments.

4. Signatures are not required for ex parte reviews.

5. Members can be moved between programs during an ex parte review.

· If moving to Medicaid, members cannot be moved to a Medically Needy, MWI, on UPP program, nor can they be moved to the NH or LTC Waiver programs if they have a contribution to the cost of care. Member participation is required (704-2).

6. Collateral contact should be made by phone when access to affordable health insurance has not been verified in the last 6 months or the agency is questioning access to affordable health insurance. If unable to obtain the necessary information after an attempt is made:

· Complete the ex parte determination, update eligibility, and set a new certification period.

· Send a notice requesting verification of the access to affordable health insurance.

· Give the member at least 10 days from the date of the notice to return verification. If verification is received, make any necessary updates and redetermine eligibility. If verification is not returned by the due date, close with proper notice. Closure should not occur prior to the end of the previously renewed certification period.

7. Set the certification period as the month after the review month (703).

8. If the member responds to the ex parte review notice of decision, treat the response as a change report (804 and 102-3).

B. When Member Participation May be Required

Below are examples when member participation may be required if you cannot gather the information without member participation (i.e. by electronic verification, collateral contact, etc.):

1. If a member would lose eligibility for all medical programs, do not close the current program. Member participation must be required (704-2).

2. If a data match finds income that has not been reported and there is not information to complete a best estimate of income, such as not having a full quarter of wages.

3. If income cannot be verified electronically or has not been verified by a reliable source within the last 6 months and is subject to change on a regular basis (i.e. Yearly COLA for retirement income, self-employment or rental income).