Ala. Admin. Code r. 560-X-25-.04

Current through Register Vol. 42, No. 7, April 30, 2024

Section 560-X-25-.04 - Application, Initial Determination Or Denial Of Eligibility, And Redetermination Of Eligibility

(1) An application is a specific written request on the designated agency application form which has been completed, dated and signed (including State acceptable electronic signatures) by the applicant and/or applicant's representative or guardian to have eligibility for categorical assistance determined. Application is required before an individual may be determined eligible for Medicaid benefits.

(2) Any person completing an application for Medicaid benefits on behalf of another must have written authority to do so. If the person being represented is unable to sign an authorization, it must be signed by his or her legal guardian, if there is one, or if there is none, then by his or her sponsor. A form entitled, "Appointment of Representative," available from the Alabama Medicaid Agency must be completed and signed by the applicant's representative. A copy of the form is in Rule 560-X-28-.01(16) of this code.

(3) A determination of eligibility is the process by which the Medicaid Agency's worker obtains the facts of the situation of the individual applying for Medicaid or Low-Income Subsidy (LIS) as related to each factor of eligibility. In the eligibility determination process, all facts and information related to eligibility which are alleged by the applicant must be substantiated, verified, and documented.

(4) A redetermination of eligibility must be made by the Medicaid Agency, the Department of Human Resources, Alabama Department of Public Health Child Health Insurance Program (CHIP), or the Social Security Administration for every Medicaid or LIS recipient at least once every twelve months. More frequent redeterminations are necessary for recipients whose circumstances are likely to change or from whom information indicates conditions have changed.

(5) When an applicant/recipient fails or refuses to provide needed information within his/her capacity, he/she may be denied or terminated from Medicaid or LIS; because eligibility cannot be determined or redetermined.

(6) Submission of an application for benefits containing a material misstatement, a material omission, or a material false statement shall result in a denial or termination of eligibility as appropriate, under such application for reapplication.

(7) Any Medicaid eligible child under age 19 who has been correctly determined Medicaid eligible is deemed to be eligible for a total of 12 months regardless of changes in circumstances other than attainment of the maximum age stated above, as long as the child remains a resident of Alabama.

Ala. Admin. Code r. 560-X-25-.04

Rule effective October 1, 1982. Amended: effective April 15, 1983; July 9, 1985; January 8, 1986; January 14, 1987. Amended: Filed August 4, 1998; effective September 9, 1998. Amended: Filed January 11, 2006; effective February 15, 2006. Amended: Filed March 13, 2008; effective April 17, 2008.

Amended by Alabama Administrative Monthly Volume XXXVI, Issue No. 12, September 28, 2018, eff. 10/26/2018.

Authors: Denise Banks, Associate Director, Policy and Training, Beneficiary Services Division

Statutory Authority: Social Security Act, Titles XVI, XIX; Sections 1935(a), 1902(a) (66), 1860D-14, and 1905(p)(3); 20 CFR 416 ; 42 CFR 423.774 and 423.904, and 42 CFR 435.