Md. Code Regs. 10.09.62.11

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.09.62.11 - 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:

(a) The basis and effective date for eligibility;

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

(c) The right to request a hearing; or

(2) For ineligible individuals:

(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.

B. Participant Responsibility.

(1) After an individual has been determined to be eligible for the separate CHIP Program and is enrolled in the separate CHIP Program, the participant or the participant's representative shall:

(a) Within 10 days of the occurrence, notify the Department if there is a change in the participant's, the participant's parent's, or the participant's guardian's:

(i) Income;

(ii) Employment;

(iii) Address; or

(iv) Health insurance coverage status;

(b) Limit use of the Medical Assistance card to the individual whose name appears on the card; and

(c) When written or electronic notice of cancellation is received, discontinue use of the Medical Assistance card on the first day of ineligibility and return the card to the Department.

(2) Failure to comply with §B(1) 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.

(3) A participant shall cooperate with the Department's quality control and audit review process, including verification of all information pertinent to the determination of eligibility.

(4) If the participant refuses to cooperate, the participant's coverage shall be terminated subject to timely and adequate notice under COMAR 10.01.04.03.

C. Unscheduled Redetermination.

(1) The Department or its designee shall:

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

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

(ii) Brought to the attention of the Department or its designee from other responsible sources;

(b) Notify the participant that redetermination is required to establish continuing eligibility; and

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

(2) Eligibility Decisions. Participants 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 because of a change in circumstances or failure to establish eligibility following a change in circumstance shall be sent notice in accordance with §A(2) of this regulation.

(3) A participant whose eligibility has been canceled may reapply at any time after the cancellation of eligibility and a new period under consideration shall be established.

D. Scheduled Redetermination. Except for children eligible as newborns of eligible individuals the Department or its designee shall make a scheduled redetermination of a child participant's eligibility at least every 12 months.

Md. Code Regs. 10.09.62.11

Regulations .11 adopted effective 50:22 Md. R. 974, eff. 11/13/2023