Eligibility Redeterminations

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HAWAII ADMINISTRATIVE RULES

TITLE 17

DEPARTMENT OF HUMAN SERVICES

SUBTITLE 12

MED-QUEST DIVISION

CHAPTER 1712.1

ELIGIBILITY REDETERMINATIONS

§17-1712.1-1 Purpose §17-1712.1-2 Annual redetermination of a MAGI beneficiary §17-1712.1-3 Annual redetermination of a MAGI- excepted beneficiary §17-1712.1-4 Redetermination due to a change in beneficiary household circumstances §§17-1712.1-5 to 17-1712.1-9 (Reserved)

Historical Note: This chapter is based substantially upon repealed chapter 17-1712. [Eff 8/1/94; R 09/30/13]

§17-1712.1-1 Purpose. This chapter establishes the circumstances, time periods, and conditions under which a redetermination of eligibility for continuing medical assistance shall be made. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§431.10, 435.916) (Imp: 42 C.F.R. §§431.10, 435.916)

§17-1712.1-2 Annual redetermination of a MAGI beneficiary. (a) The beneficiary may request assistance with an annual redetermination under the

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provisions described in subchapter 2 of chapter 17- 1711.1. (b) The annual redetermination of an individual or household, whose Medicaid eligibility is based on modified adjusted gross income methods (MAGI), shall be completed by the department no more frequently than once every twelve months. (c) The annual redetermination of Medicaid eligibility shall be based on reliable information available to the department to include information through a federal or state database as described in chapter 17-1714.1, without requiring additional information from the beneficiary. (d) If able to redetermine eligibility based on available information, the department shall notify the beneficiary as described under the provisions of chapter 17-1713.1, of the following: (1) The eligibility redetermination decision and basis; and (2) If the information is accurate, the beneficiary is not required to sign and return the notice; or (3) If the information is not accurate, the beneficiary is required to correct, sign and return the notice. (e) If the department is unable to redetermine eligibility in accordance with paragraph (c) of this section, the department shall: (1) Send a pre-populated redetermination form containing information available to the department that is needed to redetermine eligibility, allowing at least thirty days from the date the redetermination form is sent to respond and provide any necessary information through any mode of communication under the provisions of chapter 17-1711.1; (2) Upon receipt, verify the information provided by the beneficiary; and (3) Inform the beneficiary of the eligibility decision under the provisions described in chapter 17-1713.1.

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(f) A beneficiary who is terminated for failure to submit the redetermination form or necessary information, then later submits the redetermination form within ninety days after the date of termination, shall not be required to submit a new application. The new effective date of eligibility shall be the date the redetermination form is received. (g) The beneficiary shall not be required to complete an in-person interview as part of the annual redetermination process. (h) Verification of eligibility criteria may occur between scheduled eligibility redeterminations as described in subchapter 5 of chapter 17-1714.1. [Eff 09/30/13] (Auth: HRS §346-14; Imp: 42 C.F.R. §§435.531, 435.541, 435.911, 435.916, 435.952) (Imp: 42 C.F.R. §§435.531, 435.541, 435.911, 435.916, 435.952)

§17-1712.1-3 Annual redetermination of a MAGI- excepted beneficiary. (a) The beneficiary may request assistance with an annual redetermination under the provisions as described in subchapter 2 of chapter 17-1711.1. (b) The annual redetermination of an individual or household whose Medicaid eligibility is based on MAGI-excepted methodology shall be completed by the department every twelve months. (c) The department shall: (1) Send a pre-populated redetermination form containing information available to the department to respond and provide necessary information, sign and return the form through any mode of communication, at least thirty days from the date the redetermination form is sent to the beneficiary in accordance with the provisions of chapter 17-1711.1; (2) Upon receipt of a signed redetermination form, verify the information provided by the beneficiary; and

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(3) Inform the beneficiary of the eligibility decision under the provisions described in chapter 17-1713.1. (d) A beneficiary who is terminated for failure to submit the redetermination form or necessary information, then later submits the redetermination form within ninety days after the date of termination shall not be required to submit a new application. The new effective date of eligibility shall be the date the redetermination form is received. (e) The department may consider: (1) Blindness as continuing until a reviewing physician determines that an individual's vision has improved beyond the definition of blindness under the provisions described in section 17-1719-10; or (2) Disability as continuing until the department receives verification that an individual's disability no longer meets the definition of disability under the provisions described in section 17-1719-10. (f) Verification of eligibility criteria may occur between scheduled eligibility redeterminations as described in subchapter 5 of chapter 17-1714.1. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.531, 435.541, 435.911, 435.916, 435.952) (Imp: 42 C.F.R. §§435.531, 435.541, 435.911, 435.916, 435.952)

§17-1712.1-4 Redetermination due to a change in beneficiary household circumstances. (a) Between annual redeterminations of eligibility, an individual or household shall report any changes in circumstance that may affect eligibility through their elected mode of communication within ten days of the change. (b) Upon receipt of the change in circumstance information, the department shall redetermine eligibility according to the provisions of sections 17-1712.1-2 or 17-1712.1-3, as applicable.

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(c) For an individual determined eligible using MAGI-based methodology, the department shall: (1) Limit requests for additional information solely to the reported change in circumstance; (2) If able to redetermine eligibility of all requirements based on the reported change, a new twelve-month period of eligibility may be established; (3) If informed of an anticipated change, redetermine eligibility at the appropriate time of the change; (4) Process the addition of a new member to the household in accordance with paragraphs (b) and (c) of this section; and (5) Prior to making a determination of ineligibility, determine all bases of eligibility under other chapters under this subtitle; and (6) For an individual determined ineligible for Medicaid, the department shall transfer the individual's application information for other insurance affordability programs as appropriate pursuant to 42 CFR §435.1200(e). (d) For an individual determined eligible using MAGI-excepted methodology, the department: (1) May utilize the change in circumstance opportunity to collect additional information in order to complete a redetermination of eligibility for the household. Requests for non-applicant information shall be limited as described under section 17-1711.1-21(e); (2) May establish a new twelve month period of eligibility if able to redetermine eligibility of all requirements; (3) Except for the addition of a newborn to a household, shall require a beneficiary requesting the addition of a new household to submit a completed application and supporting documentation as described in chapter 17-1711.1. A redetermination of

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eligibility for the household shall be completed based upon the submitted application and information; (4) If informed of an anticipated change, shall redetermine eligibility at the appropriate time of the change; (5) Prior to making a determination of ineligibility, shall determine all bases of eligibility under other chapters of this subtitle; and (6) For an individual determined ineligible for Medicaid, the department shall transfer the individual's application information for other insurance affordability programs as appropriate pursuant to 42 CFR §435.1200(e). [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.902, 435.916, 435.1200) (Imp: 42 C.F.R. §§435.902, 435.916, 435.1200)

§§17-1712.1-5 to 17-1712.1-9 (Reserved).

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