Purpose: To explain how often the agency reviews individuals' eligibility based on the health care coverage they receive and their circumstances.
Review of Current Circumstances
- As part of the eligibility review process for a paper review form, ensure that the person answered all questions clearly and completely. If doing a review in-person or over the telephone, ensure that all eligibility factors are reviewed.
- If applicable, review the record for the Equal Access (EA) plan (see EA).
- Review the record to see if earlier actions or changes may have an impact on eligibility.
- Review for eligibility factors, especially:
- Income for all Apple Health programs; and
- Resources for Classic Apple Health programs
- Review resources the household claims to see if there are any changes to resources we earlier excluded or decided were not available.
- Review funds in joint checking accounts that we excluded earlier.
- Review the plan to exclude business property of a self-employed person to decide if the property leads to full or partial self support.
- Review the value of liquid and nonliquid resources. Look for an increase in the value of real estate, cash value of life insurance, and securities that can be sold such as stocks, bonds, and certificates of deposit.
- Review and get proof of eligibility factors that have changed.
- Review and document previous proof to ensure that:
- Previously verified factors are clear and complete in the case file; and
- We are not asking the individual to give us duplicate or unneeded proof.
- Document proof you received.
- If any changes were made, send the appropriate letter.
Incomplete and Late Reviews
If an administrative review for a renewal cannot be completed and no review has been completed over the phone or in-person, then the household is ineligible for coverage. No review form is needed if the review is completed on or before the eligibility review end date or within the first 30 days after termination for Classic cases or 90 days for MAGI.
Note: If a household does not return a review form or returns it late, check the household record for an Equal Access Plan.
If you initiate a review for CN coverage, ACES keeps Apple Health open even if the individual does not return the required proof. When pending a review, set an alert to check the case and determine if the individual returned the required proof.
- If someone does not provide the proof you asked for, close the medical AU with advance and adequate notice (see WAC 182-518-0025).
- If you receive information to establish eligibility:
- For Classic Apple Health, within 30 days after the month the review was due, reopen coverage.
- For MAGI Apple Health, within 90 days after the month the review was due, Washington Healthplanfinder reopens coverage back to the first of the month following termination of coverage.