704 Eligibility Review

Effective Date: November 1, 2024

Previous Policy

An eligibility review is the process of gathering and verifying all factors of eligibility to determine if a member remains eligible.

Reviews are required for all CHIP programs once every 12 months, and no more frequently than once every 12 months.

Exception: the member became pregnant while covered by the CHIP program. See section 222.

The eligibility agency must begin the review process early enough that a redetermination can be made before the end of the current certification period.

The agency must use all reliable information available, such as electronic data sources. Reliable information may also include:

Information received within the last 6 months from other benefit programs or reliable sources for the determination as long as no discrepancies are identified (e.g., information provided in the Supplemental Nutrition Assistance Program (SNAP) recertification (705).

Available information in the members’ account that is recent and reliable.

Information from the initial determination at application or the member’s last renewal if it relates to circumstances that generally are not subject to change (e.g., citizenship or satisfactory immigration status).

The eligibility agency must attempt a redetermination of benefits based on current, reliable information without requiring any information from the member (ex parte review see 704-1).

Any form of verification may be used as long as it does not involve asking the member. (705)

Members may move between medical programs during the ex parte review.

If available information is insufficient to determine continued eligibility, member participation in the eligibility review is required (704-2).

If an ex parte review has not been attempted and an eligibility review (online, telephonic or pre-populated) has been completed, the ex parte must be attempted before using the completed eligibility review. If the ex parte can be completed, use the completed eligibility review as a change report form (804). If the ex parte cannot be completed, use the eligibility review form to complete a member participation eligibility review 704-2).

If unable to complete the ex parte review, member participation is required (704-2).

See 703 for length of a certification period.

See 435 for budgeting of income.

See 804 and 102-3 for changes during the certification period.