Family MO HealthNet (MAGI) Manual

1890.000.00 EX PARTE REVIEW PROCESS

IM-#109 August 08, 2017IM-29, March 29, 2017

Under 42 CFR 435.909, prior to stopping a participant’s coverage under most MO HealthNet categories, with the exception of failure to cooperate, it is mandatory to explore possible eligibility under all other MO HealthNet programs. Eligibility criteria or changes in circumstance such as pregnancy, income, age, or household composition may allow a participant to move from one Family MO HealthNet program another without a new application.

NOTE: Possible eligibility for MO HealthNet for Aged, Blind or Disabled (MHABD) must also be explored if the individual claims a disability, is blind or aged (age 65 or older).

This process is called ex parte review.

  • Complete an ex parte review without requiring an application or additional information from the household unless:
    • you are exploring eligibility for MO HealthNet for the Aged, Blind or Disabled (MHABD) or MO HealthNet for Disabled Children (MHDC); and
    • there is no active MHABD/MHDC case for the household.
    • NOTE:  42 CFR 435.907 specifies that applications or existing coverage moving from MAGI to non-MAGI programs may use new applications or supplemental forms to capture information needed for non-MAGI programs.
  • Use the data sources listed in 1805.000.00 ELIGIBILITY AND VERIFICATION whenever possible to verify eligibility criteria.
  • NOTE:  Some MO HealthNet programs have different program eligibility and verification requirements than MAGI programs.  Participants may be required to submit additional paperwork for these programs.
  • Move the participant to the MO HealthNet benefits with the highest level of care for which they qualify.

If ending eligibility from one category and approving in another, process both transactions on the same day to prevent any disruption in healthcare coverage.

The following programs are time limited and will not generate Adverse Action Notices at the end of their time period:

  • Newborn (up to but not including one (1) year of age)
  • MO HealthNet for Pregnant Women (throughout pregnancy and up to 60 days post-partum)
  • Extended Women’s Health Services (EWHS) (maximum of twelve (12) months)
  • Transitional MO HealthNet (maximum of twelve (12) months)

The households are informed of the coverage timeframes at the point of approval.  When coverage for these programs ends, an ex-parte review is required. If no other eligibility exists when closing these cases, the Eligibility Specialist must send an appropriate IM-33 notice.