Every review or change in circumstances requires appropriate action and recording. Complete a review of SP-Only eligibility every 12 months. SSI-SP do not require an annual review.
When one or more changes occur, evaluate which eligibility factors may be in question to determine what action needs to be taken. Changes that may require action include: marriage, appointment of guardian, change in living arrangements, or change in income.
Reviews of SP-Only cases are to be conducted annually. The reinvestigation process should be completed through the mail. A face-to-face interview is not required. A reinvestigation can be completed without a review form (FA-402), if all necessary information is available to make a determination of continued eligibility. A case may not be closed for failure to return a review form or complete an annual reinvestigation, if continued eligibility can be established based on available information from other sources, i.e., the food stamp case, spouse's MA case, etc.. When completing a reinvestigation, a new budget, income and resource documentation, and the eligibility determination should be recorded.
Annual reviews are the same as for the MO HealthNet for the Aged, Blind or Disabled program. Refer to Sections 0840.000.00 through 0840.015.05.
An SP-Only or SSI-SP recipient loses eligibility the SP grant when he/she:
NOTE: Ineligibility for public assistance is effective for the month in which the withdrawal or termination from SSI is effective. (Regulation 40-2.140).
Follow adverse action procedures, as applicable, and close the case.
Cancel close the case and restore SP-Only or SSI-SP status if the recipient:
Refer to Common Procedures of Conversion Categories.
If an SSI-SP or SP-Only recipient enters a licensed RCF; Assisted Living (formerly RCF-II) or an intermediate/skilled nursing facility, determine whether the claimant is eligible for a higher benefit under the SNC program. If the SNC payment is higher than the conversion payment and the claimant is willing to sign a SNC application, process a SNC application. The recipient must meet the eligibility requirements for SNC to receive an SNC payment. If the claimant is eligible for SNC and this change is beneficial to the claimant, close the SSI-SP or SP-Only case and open the SNC case.
This closing of the conversion case does not terminate the claimant's right to regain conversion status if the claimant's circumstances change. To reinstate the conversion status, close the SNC and cancel close the SSI-SP, or SP case.
Recipients who are in or plan to enter a Medicaid nursing facility may be eligible for vendor payments made in their behalf to pay for their care in the nursing home. An individual may continue to receive a cash supplemental payment as opposed to a vendor payment, however the claimant is then liable for the full cost of the nursing facility care. Both a cash and vendor payment cannot be made unless the claimant was originally converted as a cash and vendor case. (See “Procedures for December 1973 Cash and Vendor Cases”, Section 0740.000.00.)
Register and process an application for MA for SSI-SP or SP-Only recipients who enter a vendor facility. Follow MA Vendor criteria and procedures (refer to Section 0815.000.00) to determine eligibility for Medicaid vendor payments. If the claimant meets MA vendor criteria, close the SSI-SP or SP-Only case and open the MA case.
These recipients can regain their conversion status when they leave a vendor situation. Close the MA case and cancel close the conversion case.
If a claimant becomes ineligible to receive OASDI or SSI as a disabled individual and receives a supplemental payment, obtain a new medical determination. The existing medical information is no longer pertinent if this information precedes Social Security's determination. When Social Security reports a denial or termination based on disability, treat this information as a change. Obtain a new medical and submit through MRT.
Once an individual is determined eligible for Medicaid, eligibility must continue uninterrupted until the individual is determined ineligible for every category of MC+/Medicaid. A termination without a review for on-going eligibility is improper. Reviews for on-going eligibility must be conducted without the involvement of the recipient, if possible. This is known as an ex-parte review.
If a change in circumstances results in a determination of ineligibility for SP-Only and SSI-SP, ineligibility for all Medicaid/MC+ categories must be established prior to taking action to close the case. All available information must be carefully reviewed. If potential eligibility exists under another category, change the case address if necessary, and continue Medicaid under the conversion case number (type of assistance A,E, or F) as a level of care T while exploring the other eligibility. Action may be taken to discontinue the cash grant while not affecting the Medicaid eligibility.
Do not ask the claimant to provide new information that is available to the agency or to re-verify current case information. In some situations it may be necessary to obtain additional information from the client to determine eligibility in another category. Do not close while attempting to complete the new eligibility determination.
If the claimant is determined eligible under another category, switch the individual to the appropriate category (an IM-1 is not necessary). Process both closing and approval transactions on the same day in order to prevent any disruption in healthcare coverage.
If the category the claimant is eligible is MA-spend down send an advance notice of adverse action (IM-80) notifying the claimant they will become spend down the month after the IM-80 expires. After the IM-80 expires, register an MA-spend down application and: