D.C. Mun. Regs. tit. 29, r. 29-9501

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 29-9501 - APPLICATION, REDETERMINATION, AND RENEWAL

9501.1

An individual may apply for Medicaid or other Insurance Affordability Programs (IAPs) using a single, streamlined application described at 42 C.F.R. Sections 435.907(b) and (c). The application and any required verification may be submitted:

(a) Over the Internet;

(b) By telephone;

(c) By mail;

(d) In person; and

(e) Through other commonly available electronic means.

9501.2

The application and any required verification may be submitted by:

(a) The applicant;

(b) An adult who is in the applicant's household or family;

(c) An authorized representative of the applicant, pursuant to Subsection 9501.33; or

(d) An individual acting responsibly on behalf of the applicant, if the applicant is a minor or incapacitated.

9501.3

Where the Department requires additional information to determine eligibility, the Department shall provide written notice that includes a statement of the specific information needed to determine eligibility; and the date by which an applicant or beneficiary shall provide the required information.

9501.4

The Department shall issue an eligibility determination, consistent with the timeframe described under § 9501.9 based on the receipt of an application that includes, at a minimum:

(a) The applicant's name;

(b) The applicant's District address; provided, that if the applicant is homeless and attests to their homelessness (consistent with § 9505.3), the applicant may select a mailing address provided from a list maintained by the Department of Human Services or provide an email address or phone number at which the Department may contact the applicant; and

(c) A signature (wet, digital, or electronic, as appropriate) provided under penalty of perjury.

9501.5

In order for the Department to determine whether an applicant meets the eligibility factors for Medicaid, the applicant shall complete the application process by providing a complete application, which shall consist of the:

(a) The information and signature required by § 9501.4;

(b) All information, including demographic information, citizenship/nationality or satisfactory immigration status, household composition, residency, and income, needed to determine eligibility; and

(c) Required verifications for financial and non-financial eligibility factors.

9501.6

The Department shall accept handwritten, telephonically recorded, and electronic signatures that conform to the requirements of federal and District law.

9501.7

The Department may not require an in-person interview as part of the application process for Medicaid eligibility determinations.

9501.8

The Department shall use the application filing date to determine the earliest date for which Medicaid can be effective. The filing date shall be the date that an application is received by the Department.

9501.9

Application timeliness standards shall be as follows:

(a) For an initial eligibility determination based on a disability, the Department shall inform the applicant of timeliness standards and determine eligibility within sixty (60) calendar days of the date that an application is received.

(b) For an initial eligibility determination for all other applicants, the Department shall inform the applicant of timeliness standards and determine eligibility within forty-five (45) calendar days of the date that an application is received.

(c) The Department may extend the sixty (60) day and forty-five (45) day periods when a delay is caused by unusual circumstances beyond the Department's control such as:

(1) Circumstances wholly within the applicant's control;

(2) Circumstances beyond the applicant's control such as hospitalization or imprisonment; or

(3) An administrative or other emergency that could not be reasonably controlled by the Department.

9501.10

Eligibility for Medicaid shall begin three (3) months before the month of application if the individual was eligible and received covered services during that period.

9501.11

The earliest possible date for retroactive eligibility shall be the first day of the third month preceding the month of application.

9501.12

Retroactive eligibility, pursuant to Subsections 9501.10 and 9501.11, shall not apply to:

(a) Qualified Medicare Beneficiaries (QMB);

(b) Individuals without dependent children eligible for Medicaid under Section 1115 of the Social Security Act on or before December 31, 2014;

(c) Individuals determined presumptively eligible by qualified hospitals; and

(d) Individuals determined presumptively eligible based on pregnancy.

9501.13

An applicant or the applicant's authorized representative pursuant to § 9501.33 may withdraw an application upon request, through a signed statement, and prior to an eligibility determination through any means identified at Subsection 9501.1.

9501.14

The Department shall renew eligibility every twelve (12) months for all beneficiaries, except for beneficiaries deemed eligible for less than one (1) year.

9501.15

A beneficiary shall immediately notify the Department of any change in circumstances that directly affects the beneficiary's eligibility to receive Medicaid, or affects the type of Medicaid for which the beneficiary is eligible.

9501.16

The Department shall redetermine eligibility for beneficiaries identified at Subsection 9501.15 at the time the change is reported.

9501.17

When renewing or redetermining eligibility, the Department shall, where possible, determine eligibility using available electronic information.

9501.18

Where the Department can renew eligibility based on available electronic information, the Department shall issue written notice of the determination to renew eligibility and its basis to the beneficiary no later than sixty (60) days before the end of the certification period. The Department shall then renew eligibility for twelve (12) months.

9501.19

A beneficiary shall not be required to sign and return the written notice identified at Subsection 9501.18 if the information provided in the notice is accurate.

9501.20

Where the information in the written notice identified at Subsection 9501.18 is inaccurate, the beneficiary shall provide the Department with correct information, along with any necessary supplemental information through any means allowed under Subsection 9501.1.

9501.21

A beneficiary may provide correct information and any necessary supplemental information pursuant Subsection 9501.20 without signature.

9501.22

Where the Department cannot determine eligibility using available information, the Department shall provide a pre-populated renewal form with information available to the Department; a statement of the additional information needed to renew eligibility; and the date by which the beneficiary shall provide the requested information.

9501.23

Where the Department provides a beneficiary with a pre-populated renewal form, to complete the renewal process, the beneficiary shall:

(a) Complete and sign the form in accordance with Subsection 9501.6;

(b) Submit the form via the Internet, telephone, mail, in person, or through other commonly available electronic means; and

(c) Provide required information to the Department before the end of the beneficiary's certification period.

9501.24

The pre-populated renewal form shall be complete if it meets the requirements identified in Subsection 9501.5.

9501.25

Where a beneficiary fails to return the pre-populated renewal form and the information necessary to renew eligibility, the Department shall issue a written notice of termination thirty (30) days preceding the end of a beneficiary's certification period.

9501.26

The Department shall terminate Medicaid eligibility when:

(a) A beneficiary fails to submit the pre-populated renewal form and the necessary information by the end of certification period; or

(b) The beneficiary no longer meets all eligibility factors.

9501.27

For an individual who is terminated for failure to submit the pre-populated renewal form and necessary information, the Department shall determine eligibility without requiring a new application if the individual subsequently submits the pre-populated renewal form and necessary information within ninety (90) days after the date of termination.

9501.28

The Department shall terminate eligibility upon a beneficiary's request.

9501.29

Upon receipt of a written request for termination of Medicaid eligibility by the beneficiary, the Department shall terminate the beneficiary's eligibility on:

(a) The last day of the month in which the Department receives the request where there are fifteen (15) or more days remaining in the month;

(b) The last day of the following month in which the Department receives the request where there are fewer than fifteen (15) days remaining in the month; or

(c) A date earlier than those referenced in Subsections 9501.29(a) through (b), upon request by the beneficiary.

9501.30

A request to terminate Medicaid eligibility shall be complete if all of the following requirements are met:

(a) The request is submitted by Internet, telephone, mail, in-person, or through other commonly available electronic means;

(b) The request is signed and dated, under penalty of perjury, in accordance with Subsection 9501.6; and

(c) The request includes all information necessary to determine the identity of the individual seeking termination.

9501.31

The Department shall provide written notice of termination no later than fifteen (15) calendar days prior to termination, except as stated under Subsection 9508.5 through Subsection 9508.7.

9501.32

An applicant or beneficiary determined to be ineligible for Medicaid shall receive an eligibility determination for other IAPs.

9501.33

An individual may designate another individual or organization to be an authorized representative to act on their behalf to assist with an application, a redetermination of eligibility, and other on-going communications with the Department. The Department shall require the following:

(a) The designation of an authorized representative shall be in writing and signed, pursuant to Subsection 9501.6, by the individual seeking representation. In the alternative, legal documentation of authority to act on behalf of an individual under District law, including a court order establishing legal guardianship or power of attorney, may serve in the place of a written authorization;

(b) The authority of an authorized representative shall be valid until the represented individual or authorized representative notifies the Department that the representative is no longer authorized to act on the individual's behalf; or there is a change in the legal document of authority to act on the individual's behalf;

(c) An authorized representative may be authorized to:

(1) Sign an application on behalf of an applicant;

(2) Receive copies of notices and other communications from the Department;

(3) Act on behalf of an individual in all other matters with the Department; and

(4) Complete and submit redetermination forms; and

(d) An authorized representative shall agree to maintain, or be legally bound to maintain, the confidentiality of any information regarding the represented individual provided by the Department.

D.C. Mun. Regs. tit. 29, r. 29-9501

Final Rulemaking published at 62 DCR 11142 (8/14/2015); amended by Final Rulemaking published at 69 DCR 12065 (10/7/2022)