704-2 Reviews Requiring Member Participation

Effective Date: January 1, 2024

Previous Policy

1. Members must participate in the CHIP review process when it’s been determined an ex parte review cannot be completed. Participation can begin as soon as it is determined an ex parte review is unsuccessful.

2. The agency will send a pre-populated review form to the member in the month before the review month. The review form will explain the review date and what the member is required to do to complete the review process. Signatures are required on reviews that require member participation and follow the same rules as application signatures found in section 102-1.

a. If the member completes the review form by the due date or during the review month, a written request for needed verification must be sent to the member. The agency must allow the member at least 10 days to provide the requested verification.

b. If the member does not return all requested verification by the due date, eligibility ends at the end of the month for which the eligibility agency gave 10-day notice.

c. The member has three months after the effective closure date to complete the review without having to re-apply.

3. If the agency cannot give 10-day notice before deciding eligibility for a new enrollment period, extend benefits to the following month; this is called the “due process month”. (See Section 803 for exceptions to 10-day advanced notice.)

· For a CHIP eligible child who turns age 19 before or during the review month, benefits cannot be extended during the eligibility review, unless the child became pregnant while covered by CHIP and has not completed their 12 months of postpartum coverage.

4. If the member provides all the requested verifications either by the verification due date or after the due date but before the end of the review month, the eligibility agency will proceed with the eligibility decision.

a. The agency continues eligibility into the following month (the “due process month”) while it makes a decision if needed.

b. Do not end or adversely change eligibility until the end of the month for which the eligibility agency can give 10-day notice. This includes changing CHIP plans from B to C.

5. If eligibility continues into the due process month, the member must provide verification by the verification due date.

a. If the member provides verification by the due date, complete the review and send the notice of the eligibility decision. Do not end or adversely change eligibility until the end of the month for which the eligibility agency can give 10-day notice.

b. If the member provides verification by the due date but the agency cannot complete review and notify the member of an adverse action before 10-day notice, approve a second due process month. Complete the review and send a notice of decision.

c. If the member fails to provide verification by the due date, close the case effective the end of the due process month and send notice of decision.

d. If the member provides verification after the due date but before the end of the due process month, the date verifications are received is a new application date. If eligible, benefits are effective the first day of the month after the due process month.

6. If additional verification is requested, give the member at least ten days to provide the verification. Approve a second due process month if needed.

7. If the member fails to complete the review process the case will close because the member failed to complete the review.

Eligibility ends at the end of the month in which proper notice can be sent.

The member has three months following the closure date to complete the review without submitting a new application.

If eligibility is extended into a due process month, the three-month period begins the month after the due process month.

The benefit effective date is the first day of the month in which the member contacts the eligibility agency or submits all previously requested verification.

There is no retroactive benefit for CHIP.

The member may request coverage for the 4-day grace period (See Section 701-2 ).

An interview or application form is not required.

Eligibility does not continue while the agency makes a decision.

Application processing timeframes apply.

If the member provided updated TPL information during the failed review period, do not request it again to complete the review.

If the member fails to respond within the three months after the case closes for failure to complete the review, require a new application.

If an overpayment investigation determines individuals were not eligible in the review month and a due process month was issued, the referral must include the due process month (See Section 806-2 ).

To determine what action to take for changes reported after the review requiring member participation is completed, see section 804 and 102-3 .