Override Eligibility Determination

 

Use this guide to override system generated eligibility determination results.

 

 

 

From the Home Page access the Admin Dashboard screen.

 

Applications’ eligibility determination results can be overridden if documentation or an explanation is provided and deemed sufficient to change the outcome of the determination. This assessment occurs outside the system.

 

 

 

 

 

 

 

Process Steps

 

To manually override system generated eligibility determination results:

 

1.      Click the Manage an Individual Account link in the Admin Dashboard.

·        The Account Search screen is displayed.

2.      Enter search criteria for the account which eligibility results are to be overridden:

a.      Select Individual from the Role drop down menu.

b.      Enter the first name of the account’s primary applicant in the First Name textbox.

c.      Enter the middle name of the account’s primary applicant in the Middle Name textbox.

d.      Enter the last name of the account’s primary applicant in the Last Name textbox.

e.      Enter the date of birth of the account’s primary applicant in the Date of Birth textbox in the format MM/DD/YYYY or select it from the calendar.

f.       Enter the social security number of the account’s primary applicant in the Social Security Number textbox in the format XXX-XX-XXXX.

g.     Enter the account number in the Account ID textbox.

h.      Enter the Application Received Date from and the Application Received Date to fields in the format MM/DD/YYYY or select them from the calendar.

 

None of the fields to enter/select search criteria is mandatory; however, at least one must be selected or entered for the search to be completed.

 

 

3.      Click on the Search button.

·        Accounts that match the criteria are displayed.

 

After the results are displayed, the search criteria can be modified by manually entering the new information. To clear the criteria, click the Reset button.

 

 

4.      Select the radio button adjacent to the account.

5.      Select Override Eligibility Determination from the Admin Functions drop down menu.

6.      Click Submit.

·        The Manually Override Determination Results screen is displayed.

 

 

The Manually Override Determination Results screen displays a table of the eligibility determination results for members of a household. The table shows the name of the individual, program, results, aid category code, Medicaid premium amount, APTC amount, CSR tier level, and eligibility start and end dates.

 

 

 

7.      Select the radio button adjacent to the household member and program whose determination results are to be overridden.

 

Applicants can only be eligible for one program at a time.

 

If an applicant is eligible for a program, his/her eligibility in that program needs to be terminated (i.e., it needs to be changed to “Ineligible”) in order to be eligible for a different program. 

 

 

 

 

 

 

 

 

8.      Enter the override information in the Your Eligibility Results section:

 

a.      The Program field is pre-populated as Medicaid or QHP, depending on the selection made in step 7.

 

b.      Select the result for the override from the Result drop down menu. Options in this dropdown depend on the program being overridden. Options are:

 

                                                    i.     For MAGI Medicaid: MAGI Medicaid Eligible, MAGI Medicaid Pending and MAGI Medicaid Ineligible.

 

                                                   ii.     For QHP options are: Eligible, Conditionally Eligible and Ineligible. APTC Eligible

 

c.      Select the aid category code from the Aid Category Code drop down menu – this field is active only for Medicaid. Options are:

 

                                                    i.     Low Income Families Medicaid (LIF) – Child

                                                   ii.     Low Income Families Medicaid (LIF) – Adult

                                                  iii.     Deemed Newborn Medicaid

                                                 iv.     Rite Care Children under 1

                                                   v.     Rite Care Children under 6

                                                 vi.     Rite Care Children 6 to 18 type 1

                                                vii.     Rite Care for Pregnant Women

                                               viii.     Parent/Caretaker Category

                                                 ix.     CHIP-like MA 1 Category 157% FPL w/Ins

                                                   x.     CHIP-like MA 1 Category 157-190% FPL w/Ins

                                                 xi.     CHIP-like MA 1 Category 190-200 FPL w/Ins

                                                xii.     CHIP-like MA 1 Category 200-261% FPL w/Ins

                                               xiii.     CHIP 1 Category 157 FLP% w/o Ins

                                              xiv.     CHIP 1 Category 157-190% FLP w/o Ins

                                                xv.     CHIP 1 Category 190-200% FLP w/o Ins

                                              xvi.     CHIP 1 Category 200-261% FLP w/o Ins

                                             xvii.     CHIP-like MA 2 Category 157% FPL w/Ins

                                            xviii.     CHIP-like MA 2 Category 157-190% FPL w/Ins

                                              xix.     CHIP-like MA 2 Category 190-200% FPL w/Ins

                                                xx.     CHIP-like MA 2 Category 200-261% FPL w/Ins

                                              xxi.     Unborn CHIP-LIKE ma W/ Ins

                                             xxii.     Unborn CHIP w/o Ins

                                            xxiii.     Childless Adult Medicaid

                                           xxiv.     PE -  Foster Care Medicaid

                                             xxv.     PE – Low Income Families Medicaid (LIF) – Child

                                           xxvi.     PE – Low Income Families Medicaid (LIF) – Parent

                                          xxvii.     PE – Rite Care Children under 1

                                         xxviii.     PE – Rite Care Children under 6

                                           xxix.     PE – Rite Care Children 6 to 18 type 1

                                             xxx.     PE – Rite Care for Pregnant Women

                                           xxxi.     PE – Parent/Caretaker Category

                                          xxxii.     PE – Childless Adult Medicaid

xxxiii.    Parent Caretaker Premium Assistance

 

d.      Enter the Medicaid premium amount in the Medicaid Premium Amount textbox – this field is active only for Medicaid.

 

e.      Enter the APTC amount in the APTC Amount textbox - this field is active only for QHP.

 

f.       Enter the CSR tier level in the CSR Tier Level textbox - this field is active only for QHP. Options are:

 

                                                    i.     1

                                                   ii.     2

                                                  iii.     3

                                                 iv.     4

                                                   v.     5

 

g.     Select the eligibility start and end dates from the calendar.

 

h.      Enter account notes in the Account Notes textbox.

 

9.      Click the Override Eligibility button.

 

Once the Override Eligibility button is clicked, eligibility results are overridden. Note that there is no confirmation message alerting of this change, however, changes are displayed in the Manually Override Determination Results screen.

 

 

 

 

       

 

·        The eligibility status of the account is changed.

 

·        The Manually Override Determination Results screen is displayed.

 

 

Results of the Procedure

 

The eligibility results are overridden.

 

The individual whose eligibility was changed receives a notification of the new eligibility outcome and information about how to proceed.