Eligibility Online Manual
Purpose: This section will provide information on reinstatement of Medicaid benefits.
Current Policy Effective Date: September 1, 2018
Date Last Reviewed: July 9, 2018
Previous Policy: November 1, 2015
POL M1405: REINSTATEMENT
1. Closed Cases May Be Reinstated
Closed cases may be reinstated for the following reasons:
Client is determined eligible based on new information.
An administrative hearing has been requested timely.
2. Client Must Provide Required Information For Reinstatement
The following information may be required for reinstatement:
Verification of eligibility factors in question.
New application after a 90-day break for all programs.
3. Reinstate Benefits Effective Month of Closure
4. Reinstatement of 12 Month Extended Medical Benefits
The 12 month period will not be interrupted and will continue as if there were no gap in benefits.
5. Client Must Request Reinstatement Within Specified Timeframe
Clients have the right to continued medical benefits pending an administrative hearing when the hearing and continued benefits are requested within ten days of the date on the closure notice.
6. Client Must Be Notified of The Requirement to Pay Excess Benefits
If the hearing decision is against the client, they may be required to pay back Medicaid for services provided during the hearing process.
7. Reinstate Benefits Due to Administrative Hearing
Reinstated benefits due to an administrative hearing will continue until one of the following occurs:
Hearing decision is received.
Client requests closure of case.
Client becomes ineligible due to not meeting another eligibility factor or program requirement and fails to request an administrative hearing within ten days on the subsequent closure notice.
Client becomes ineligible due to a mass change pending the hearing decision.
8. Client’s Case May Be Closed
Client’s case will be closed when the hearing officer rules in favor of the agency.
Defining Requirement: 42 CFR 435.914
42 CFR 431, Subpart E
Social Security Act, § 19
1. Reinstatement is defined as restoring the case to eligible status when the client is determined eligible based on new information, or an administrative hearing has been requested timely.
1. Accept information/verification of eligibility factors when received.
2. Determine eligibility.
3. Revert case to “open” in WES.
4. Authorize case on the appropriate screen in WES.
5. Send approval notice.
Closing Cases After Administrative Hearing
1. Close case in WES.
2. Issue a 15-Day Notice of adverse action.