Ariz. Admin. Code § 9-28-411

Current through Register Vol. 30, No. 50, December 13, 2024

Section R9-28-411 - Changes, Redeterminations, and Notices

A. Reporting and verifying changes.

1. A person shall report to the ALTCS eligibility office the following changes for a person, a person's spouse, or a person's dependent children under 42 CFR 435.916:

a. A change of address;

b. An admission to or discharge from a medical facility, public institution, or private institution;

c. A change in the household's composition;

d. A change in income;

e. A change in resources;

f. A determination of eligibility for other benefits;

g. A death;

h. A change in marital status;

i. An improvement in the person's medical condition;

j. A change in school attendance;

k. A change in Arizona state residency;

l. A change in citizenship or alien status;

m. Receipt of an SSN under R9-22-305;

n. A transfer of assets under R9-28-409;

o. A change in trust income and disbursements in accordance with state and federal law;

p. A change in first- or third-party liability that may be responsible for payment of all or a portion of the person's medical costs;

q. A change in first-party medical insurance premiums;

r. A change in the household expenses used to calculate the community spouse monthly income allowance described in R9-28-410;

s. A change in the amount of the community spouse monthly income allowance that is provided to the community spouse by the institutionalized spouse under R9-28-410; and

t. Any other change that may affect the person's eligibility or share-of-cost.

2. A change shall be reported either orally or in writing as described under R9-22-306

.

B. Processing of changes and redeterminations. A person's eligibility shall be redetermined at least one time every 12 months and when changes occur, under 42 CFR 435.916. A person's share-of-cost, specified in R9-28-408, shall be redetermined whenever a change occurs that may affect the post-eligibility computation of income.

C. Actions that may result from a redetermination or change. Processing a redetermination or change shall result in one of the following findings:

1. No change in eligibility or the post-eligibility computation of income;

2. Discontinuance of eligibility if a condition of eligibility is no longer met;

3. Suspension of eligibility if a condition of eligibility is temporarily not met;

4. A change in the post-eligibility computation of income and the person's share-of-cost; or

5. A change in service from ALTCS to ALTCS acute care services, or from ALTCS acute care services to ALTCS, caused by changes in a person's living arrangement, specified in R9-28-406, or a transfer of assets specified in R9-28-409.

D. Notices.

1. Contents of notice. The Administration shall issue a notice when an action is taken regarding a person's eligibility or computation of share-of-cost. The notice shall contain the following information:

a. A statement of the action being taken;

b. The effective date of the action;

c. The specific reason for the intended action;

d. The actual figures used in the eligibility determination and specify the amount by which the person exceeds income standards if eligibility is being discontinued because either a person's resources exceed the resource limit , or a person's income exceeds the income limit;

e. The specific law or regulation that supports the action, or a change in federal or state law that requires an action;

f. An explanation of a person's right to request an evidentiary hearing as described under 9 A.A.C. 34; and

g. An explanation of the date by which a request for hearing must be received so that eligibility or the current share-of-cost may be continued.

2. Advance notice of changes in eligibility or share-of-cost. "Advance notice" means a notice that is issued to a person at least 10 days before the effective date of change. Except as specified in subsection (D)(3), advance notice shall be issued whenever the following adverse action is taken:

a. To discontinue or suspend eligibility if an eligible person no longer meets a condition of eligibility, either ongoing or temporarily;

b. To affect post-eligibility computation of income and increase a person's share-of-cost; or

c. To reduce benefits from ALTCS to ALTCS acute care services due to a change from a long-term care living arrangement to an acute care living arrangement, specified in R9-28-406(B), or due to a transfer with uncompensated value, specified in R9-28-409.

3. Adverse actions. An applicant or member may appeal, as described under 9 A.A.C. 34, by requesting a hearing from the Administration or its designee concerning any of the adverse actions if:

a. A person provides a clear, written statement, signed by the person, that a person no longer desires services;

b. A person provides information that requires termination of eligibility or an increase in the share-of-cost and the person signs a clear written statement waiving advance notice;

c. A person cannot be located and mail sent to that person has been returned as undeliverable;

d. A person has been admitted to a public institution where the person is ineligible for ALTCS under R9-28-406; or

e. A person has been approved for Medicaid in another state;

f. The Administration has information that confirms the death of the person;

g. The person's primary care provider has prescribed a change in the level of medical care; or

h. The notice involves an adverse determination regarding the PAS, specified in A.R.S. § 36-2936.

E. Transitional. HCBS services may be provided to a person who is no longer at risk of institutionalization but who continues to require significant long-term care services under A.R.S. § 36-2936(D).

Ariz. Admin. Code § R9-28-411

New Section adopted by final rulemaking at 5 A.A.R. 369, effective January 6, 1999 (Supp. 99-1). Amended by final rulemaking at 20 A.A.R. 193, effective 1/7/2014.