Current through August, 2024
(a) Any applicant
not determined eligible or ineligible by the thirtieth day from the date of
application shall be determined presumptively eligible for the social service
for which the individual applied effective the thirty-first day from the date
of application.
(b) A determination
of presumptive eligibility shall not constitute a final disposition. The
application shall be processed and disposition of the application shall be made
as soon as possible. The applicant shall remain presumptively eligible until
the application is either approved or denied. The applicant shall be informed
of the decision.
(c) On the
thirty-first day from the date of application, the department shall send a
written notice of presumptive eligibility to all applicants who have not been
notified of approval or denial.
(d)
The cost of services for which the application was made shall be authorized for
services received beginning the thirty-first day until presumptive eligibility
is no longer effective when:
(1) The
applicant submits to the department a bill or receipt for payment within thirty
days of the date indicated on the bill or receipt; and
(2) The amount paid does not exceed the
department's rate of payment for the kind of service received.
(e) The following conditions shall
apply in order to terminate presumptive eligibility when the applicant is
determined eligible:
(1) Presumptive
eligibility shall end on the day the disposition is made. The applicant shall
be notified of full eligibility; and
(2) The cost of services for which the
application was made shall-be authorized from the date of application according
to the department's rate of payment, if the client submits a bill or receipt
for services received during that time.
(f) The following conditions shall apply in
order to terminate presumptive eligibility when the applicant is determined
ineligible:
(1) On the day the department
determines the applicant ineligible, the department shall mail the applicant
notice to this effect;
(2)
Presumptive eligibility shall terminate three days from the date the notice is
mailed;
(3) The cost of services
for which the individual applied and received during presumptive eligibility
shall be authorized if the applicant submits a bill or receipt for payment
within thirty days of the date indicated on the bill or receipt. Payment shall
be made according to the rate of payment for the kind of service
rendered;
(4) If a fair hearing is
requested, no payments shall be made for service received after presumptive
eligibility terminated and while the fair hearing request is pending;
(5) If a fair hearing decision is in the
applicant's favor, the applicant shall be determined eligible from the date of
application. Costs for services received from the date of application shall be
paid at the department's rate of payment for that particular service when:
(A) The services are the kind of services for
which the individual applied; and
(B) The applicant submits a bill or receipt
to the department; and
(6) If a fair hearing decision is adverse to
the applicant, the applicant shall remain ineligible and responsible for costs
incurred prior to as well as after the period of presumptive
eligibility.
