Participants of the MO HealthNet for the Aged, Blind, and Disabled (MHABD) program are required to report changes in circumstance affecting eligibility factors within ten calendar days of the change. Any necessary action resulting from a change must be taken within ten calendar days of the date the participant reports the change. If the change in circumstance results in any change to eligibility, such as a change in level of coverage, change in spend down or premium amount, or ineligibility, the agency must notify the participant.
NOTE: While the date of the change is usually considered as the date that the change happened, when the change is obtaining employment or a change in rate of pay, the change date is considered to be the date of the first paycheck or first paycheck with the changed rate of pay.
If the action results in increased coverage or a better benefit, it shall be effective the month of the report. If the system does not adjust coverage for the appropriate months, staff should complete necessary actions to ensure that the correct coverage is authorized for those months.
NOTE: If the change is not reported within 10 calendar days and would result in an increase in coverage, the change is effective the month of report, not the month in which the change actually occurred.
There are circumstances when eligibility for more than one MHABD coverage type exists. This commonly occurs between the Spend Down, Ticket to Work, and SLMB2 programs.
Decisions regarding coverage options must be made by the participant or their Authorized Representative. Some of these changes can cause a significant cost difference for the participant. It is the responsibility of FSD staff to contact the participant to discuss their coverage options, and record the participant’s coverage choice in the eligibility system. If the participant does not respond to a Request for Contact letter within 10 days, FSD staff shall enter a decision based on the level of coverage currently being received, past coverage history, or the lowest cost option. Comments must be added to the eligibility system documenting attempts to contact the participant and support for the coverage option authorized. The participant must be sent the appropriate adverse action and action notices including the option to appeal the decision.
An Advance Notice of Adverse Action is required before any adverse action can be taken. Please refer to 0130.015.10 Advance Notice of Adverse Action Required and 0130.015.20 Exceptions to Advance Notice of Adverse Action for additional information.
The following are examples of case outcomes that would require an Advance Notice of Adverse Action- this list is not all-inclusive:
- change in level of care from vendor to non-vendor;
- change from non-spenddown to spenddown;
- increase in spend down amount;
- increase in TWHA premium;
- change from spend down/non-spend down to Gateway; or
- change that results in ineligibility for all types of MO HealthNet coverage.
When a change in circumstance results in the participant no longer being eligible for MHABD coverage, an ex-parte review must be completed to pursue eligibility for other MO HealthNet programs. Please review MHABD manual section 0840.015.05 Pre-closing Ex-parte Review for additional information.