Current through Bulletin 2024-06, March 15, 2024
(1) The Department adopts and incorporates by
reference
42 CFR
435.911 and
435.912,
October 1, 2013 ed., regarding eligibility determinations.
(2) At application and review, the
eligibility agency shall determine whether the individual is eligible for
Medicaid, Refugee Medical or CHIP.
(a) An
individual who qualifies for Medicaid or Refugee Medical without paying a
spenddown or for Medicaid Work Incentive (MWI ) without paying an MWI premium
may not enroll in PCN.
(b) An
applicant who is eligible for Medicaid, Refugee Medical or CHIP during the
application month, or a Medicaid, Refugee Medical or CHIP recipient who
requests PCN enrollment during an open enrollment period, may enroll in PCN in
accordance with Subsection
R414-310-12(1).
(3) An individual open
on Medicaid, Refugee Medical or UPP may request to enroll in PCN.
(a) A new application form is not required.
(b) The rules in Section
R414-310-12
govern the effective date of enrollment.
(c) If the individual is moving from UPP, the
eligibility agency shall waive the open enrollment requirement if there is no
break in coverage.
(d) If the
individual is moving from Medicaid or Refugee Medical, the eligibility agency
shall waive the open enrollment period if the individual was previously on PCN,
became eligible for Medicaid or Refugee Medical, and requests to reenroll in
PCN without a break in coverage.
(e) If the individual is moving from Medicaid
or Refugee Medical and was not previously on PCN, or there has been a break in
coverage of one or more months, the individual must reapply during an open
enrollment period.
(f) All other
eligibility requirements must be met.
(4) The eligibility agency shall complete an
eligibility determination for each application unless:
(a) the applicant voluntarily withdraws the
application and the eligibility agency sends a notice to the applicant to
confirm the withdrawal;
(b) the
applicant dies;
(c) the applicant
cannot be located; or
(d) the
applicant does not respond to requests for information within the 30-day
application period or by the verification due date, if the verification date is
later.
(5) The
eligibility agency shall complete a periodic review of an enrollee's
eligibility for medical assistance in accordance with the requirements of
42 CFR
435.916.
(a) The agency may request a recipient to
contact the agency to complete the eligibility review.
(b) The agency shall provide the recipient a
written request for verification needed to complete the review.
(c) The agency shall provide proper notice of
an adverse decision.
(d) If the
agency cannot provide proper notice of an adverse decision, the agency extends
eligibility to the following month to allow for proper notice.
(6) If a recipient fails to
respond to a request to complete the review or fails to provide all requested
verification to complete the review, the eligibility agency shall end
eligibility effective the end of the month for which the agency sends proper
notice to the recipient.
(a) If the recipient
contacts the agency to complete the review or returns all requested
verification within three calendar months of the closure date, the eligibility
agency shall treat such contact or receipt of verification as a new
application. The agency may not require a new application form.
(b) The application processing period applies
to this request to reapply.
(c)
Eligibility can begin in the month the client contacts the agency to complete
the review if all verification is received within the application processing
period.
(d) If the recipient fails
to return the verification timely, but before the end of the three calendar
months, eligibility becomes effective the first day of the month in which all
verification is provided and the individual is found eligible.
(e) The eligibility agency may not continue
eligibility while it makes a new eligibility determination.
(f) The eligibility agency shall waive the
open enrollment requirement during these three calendar months.
(g) If the enrollee does not respond to the
request to complete the review for PCN during the three calendar months
immediately following the review closure date, the enrollee must reapply for
PCN and meet all eligibility criteria.
(7) If the individual files a new application
or makes a request to reenroll within the calendar month that follows the
effective closure date when the closure is for a reason other than incomplete
review, the eligibility agency shall waive the open enrollment period and
process the request as a new application.
(8) The enrollee must reapply if the case
closes for one or more calendar months for any reason other than an incomplete
review.
(9) The eligibility agency
shall comply with the requirements of
42
CFR 435.1200(e), regarding
transfer of the electronic file for the purpose of determining eligibility for
other insurance affordability programs.