Md. Code Regs. 10.09.43.15

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.09.43.15 - Post-Eligibility Requirements

A. Notice of Eligibility Determination. The Department shall inform the representative of the applicant's legal rights and obligations and give the representative written notification of the following:

(1) For eligible persons:

(a) A finding of eligibility;

(b) The period of coverage; and

(c) The right to request a hearing; and

(2) For ineligible persons:

(a) A finding of ineligibility;

(b) The reason for the finding;

(c) The regulation supporting the finding; and

(d) The right to request a hearing.

B. Representative Responsibility.

(1) The representative shall notify the Department within 10 working days of changes affecting the recipient's eligibility.

(2) The representative shall limit use of MCHP Premium benefits to the eligible individuals.

(3) If written notice of cancellation is received, the representative shall ensure that the recipient discontinues use of MCHP Premium benefits on the first day of ineligibility.

(4) Failure to comply with the provisions of §B(1)-(3) of this regulation may result in:

(a) The termination of assistance; or

(b) Referral to the Department for fraud investigation, or for criminal or civil prosecution.

(5) The representative shall cooperate with the State's Medical Assistance quality control review process, including verification of all information pertinent to the determination of eligibility.

(6) If the representative refuses to cooperate, the recipient's coverage shall be terminated.

C. Unscheduled Redetermination.

(1) The Department shall:

(a) Promptly make an unscheduled redetermination of a recipient's eligibility if changes in circumstances or relevant facts are:

(i) Reported by someone on the recipient's behalf; or

(ii) Brought to the attention of the Department from other responsible sources; and

(b) Notify the representative of the required information and verifications needed to determine eligibility and the time standards in acting in the redetermination process.

(2) Eligibility Decisions. Recipients who are determined:

(a) Eligible for the remainder of the certification period shall be sent notice in accordance with §A(1) of this regulation; or

(b) 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(2) of this regulation.

(3) A recipient whose eligibility has been canceled may reapply for MCHP at any time.

D. Scheduled Redetermination.

(1) Redetermination is required to establish continued eligibility.

(2) Redetermination shall be scheduled annually.

(3) Completion of the application and determination of eligibility for MCHP by the LHD or the LDSS is required for renewal for program eligibility.

Md. Code Regs. 10.09.43.15

Regulations .15 adopted as an emergency provision effective July 1, 2001 (28:12 Md. R. 1102); adopted permanently effective September 3, 2001 (28:17 Md. R. 1556)
Regulation .15D amended effective November 10, 2003 (30:22 Md. R. 1580)