10.09.24.12

.12 Post-Eligibility Requirements.

A. Notice of Eligibility Determination. The Department or its designee shall inform an applicant of the applicant's legal rights and obligations and give the applicant written or electronic notification of the following:

(1) For eligible individuals in MAGI coverage groups:

(a) The basis and effective date for eligibility;

(b) Instructions for reporting changes that may affect the recipients eligibility; and

(c) The right to request a hearing.

(2) For eligible individuals in MAGI Exempt coverage groups:

(a) A finding of eligibility, the beginning and ending dates for coverage; and

(b) The right to request a hearing.

(3) For ineligible individuals in MAGI coverage groups:

(a) A finding of ineligibility, the reason for the finding, and the regulation supporting the finding;

(b) Information regarding application for MAGI exempt coverage groups; and

(c) The right to request a hearing.

(4) For ineligible individuals in MAGI exempt coverage groups:

(a) A finding of ineligibility, the reason for the finding, and the regulation supporting the finding; and

(b) The right to request a hearing.

B. Recipient Responsibility.

(1) A recipient or his representative shall notify the Department or its designee within 10 working days of changes that may affect eligibility.

(2) A recipient or his representative shall limit use of the Medical Assistance card to the person whose name appears on the card.

(3) Third-Party Liability.

(a) A recipient or his representative shall notify the Department or its designee within 10 working days when medical treatment has been provided as a result of any accident or other occurrence in which a third party might be liable.

(b) Recipients shall cooperate with the Department or its designee in completing a form designated by the Department to report all pertinent information that would assist the Department or its designee in seeking reimbursement.

(c) In accident situations, recipients shall notify the Department or its designee of the time, date, and location of the accident, the name and address of the attorney, the names and addresses of all parties and witnesses to the accident, and the police report number if an investigation is made.

(4) When written notice of cancellation is received, a recipient shall discontinue use of the Medical Assistance card on the first day of ineligibility and return it to the Department or its designee.

(5) Failure to comply with the provisions of §B(1), (2), and (3) of this regulation may result in the termination of assistance.

(6) Failure to comply with the provisions of §B(1)—(4) of this regulation may result in legal action, referral to the Department or its designee for reimbursement, fraud investigation, or both, for illegal use of the Medical Assistance card.

(7) Recipients shall cooperate with the Departmentís quality control and audit review process, including provision and verification of all information pertinent to eligibility determination. Failure to cooperate may result in the termination of coverage.

C. Redeterminations.

(1) Redetermination for Former SSI Recipients.

(a) The Department or its designee shall promptly redetermine eligibility when notice has been received from the Social Security Administration that an individual's SSI benefits have been terminated.

(b) When notice of SSI termination is received, Department or its designee shall notify the person that redetermination is required to establish continuing eligibility and shall make the application available to him.

(c) When the written or electronic, signed application is received by the Department or its designee, a new period under consideration will be set. The new period will be related to the date the application is received but may not include any months in which the individual was entitled to coverage under the current certification period.

(d) The Department or its designee shall notify the individual or his representative of the required information and verifications needed to determine eligibility and the time standards in acting in the redetermination process.

(e) All non-financial and financial factors for continuing eligibility shall be met.

(f) The following applies when the individual is determined ineligible for Medical Assistance:

(i) When the SSI termination is received by the tenth day of the month, the Department or its designee shall cancel certification effective the end of the month, unless the recipient requests a hearing in accordance with COMAR 10.01.04.

(ii) When the SSI termination notice is received after the tenth day of the month, the Department or its designee shall cancel certification effective the end of the following month unless the recipient requests a hearing in accordance with COMAR 10.01.04.

(h) Notice of Eligibility Decisions.

(i) Eligible Individuals. Individuals who are determined eligible for a new period under consideration shall be sent notice in accordance with §A(1) and (2) of this regulation.

(ii) Ineligible Individuals. Individuals determined ineligible shall be sent notice in accordance with §A(3) and (4) of this regulation.

(i) When ineligibility is due to excess income only, the person will be provided with an explanation of the spend-down provision. Spend-down eligibility may be established at any time during the new period under consideration.

(2) Unscheduled Redetermination.

(a) The Department or its designee shall promptly make unscheduled redetermination when:

(i) The person's circumstances suggest future changes which may affect eligibility before the due date of a scheduled redetermination;

(ii) Relevant facts or changes in circumstances are reported by the recipient or someone on his behalf; or

(iii) Relevant facts or changes are brought to the attention of the Department or its designee from other responsible sources.

(b) The Department or its designee shall notify the recipient that redetermination is required to establish continuing eligibility. Notification will be sent in a timely manner so that a decision of eligibility will be made within 30 days from the date of change.

(c) The Department or its designee shall notify the recipient of the required information and verifications needed to determine eligibility and the time standards in acting in the redetermination process.

(d) The Department or its designee may not require the recipient or his representative to appear in unless the Department or its designee has determined that a face-to-face contact is necessary to make an accurate eligibility determination, or the recipient requests a face to face interview.

(e) All non-financial and financial factors for continuing eligibility shall be met.

(f) Eligibility Decisions.

(i) Eligibility Continued for the Remainder of the Certification Period. Recipients who are determined eligible for the remainder of the certification period will be sent notice in accordance with §A(1) and (2) of this regulation.

(ii) Recipients Determined Ineligible for the Remainder of the Certification Period. Recipients determined ineligible for the remainder of the certification period because of a change in circumstances or failure to establish eligibility following a change in circumstances, shall be sent notice in accordance with §A(3) and (4) of this regulation.

(g) A person may reapply at any time after the cancellation of current eligibility and a new period under consideration will be established.

(3) Scheduled Redetermination.

(a) The Department or its designee shall make scheduled redeterminations at least once every 6 months for noninstitutionalized individuals certified under Regulation .11B(3) of this chapter and at least once every 12 months for institutionalized individuals certified under Regulation .11D(3) of this chapter.

(b) The Department or its designee shall notify the recipient that redetermination is required to establish continuing eligibility. The notice and application will be sent at least 45 days before expiration of the current certification period.

(c) When the written, telephonic, or electronic, signed application is received by the Department or its designee, a new period under consideration will be set. The new period will be related to the date the application is received but may not include any months in which the individual was entitled to coverage under the current certification period.

(d) A recipient shall be treated the same as an applicant at the time of scheduled redetermination.

(e) All nonfinancial and financial factors of eligibility shall be met.

(f) The local Department or its designee shall make timely decisions in accordance with the provisions of Regulation .04H of this chapter.

(g) Eligibility Decisions.

(i) Eligibility Established. Applicants who are determined eligible for a new period under consideration shall be sent notice in accordance with §A(1) and (2) of this regulation.

(ii) Ineligibility Established. Applicants determined ineligible for the new period under consideration shall be sent notice in accordance with §A(3) and (4) of this regulation.

(h) When ineligibility is due to excess income only, the applicant will be provided with an explanation of the spend-down provision. Spend-down eligibility may be established at any time during the new period under consideration.

D. Subsequent Application. A person may reapply when eligibility is not met during the periods established in §C(1) and (3) of this regulation.