Md. Code Regs. 10.09.24.12

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

Section 10.09.24.12 - Post-Eligibility Requirements

A. Notice of Eligibility Determination. The local department of social services shall inform an applicant of his legal rights and obligations and give the applicant written notification of the following:

(1) For eligible persons:

(a) A finding of eligibility, the beginning and ending dates for coverage; and

(b) The right to request a hearing.

(2) For ineligible persons:

(a) A finding of ineligibility, the reason for the finding, and the regulation supporting the finding; and

(b) The right to request a hearing.

B. Recipient Responsibility.

(1) A recipient or his representative shall notify the local department of social services within 10 working days of changes affecting the eligibility of a member of the assistance unit.

(2) A recipient or his representative shall limit use of the Medical Assistance card to the person whose name appears on the card.

(3) Third-Party Liability.

(a) A recipient or his representative shall notify the local department of social services within 10 working days when medical treatment has been provided as a result of any accident or other occurrence in which a third party might be liable.

(b) Recipients shall cooperate with the local department of social services in completing a form designated by the Department to report all pertinent information that would assist the Medical Care Compliance Administration in seeking reimbursement.

(c) In accident situations, recipients shall notify the local department of social services of the time, date, and location of the accident, the name and address of the attorney, the names and addresses of all parties and witnesses to the accident, and the police report number if an investigation is made.

(4) When written notice of cancellation is received, a recipient shall discontinue use of the Medical Assistance card on the first day of ineligibility and return it to the Medical Care Operations Administration.

(5) Failure to comply with the provisions of §B(1), (2), and (3) of this regulation may result in the termination of assistance.

(6) Failure to comply with the provisions of §B(1)-(4) of this regulation may result in legal action, referral to the Medical Care Compliance Administration for reimbursement, fraud investigation, or both, for illegal use of the Medical Assistance card.

(7) Recipients shall cooperate with the State's Quality Control review process, including provision and verification of all information pertinent to eligibility determination. Failure to cooperate shall result in the following actions:

(a) The Quality Control Division shall notify the local department of social services of a recipient's failure to cooperate;

(b) The local department of social services shall immediately attempt to secure the recipient's cooperation;

(c) If the recipient still refuses to cooperate, his coverage shall be terminated in accordance with this provision, subject to the regulation governing timely and adequate notice.

C. Redeterminations.

(1) Redetermination for Former SSI Recipients.

(a) The local department of social services shall promptly redetermine eligibility when notice has been received from the Social Security Administration that a person's SSI benefits have been terminated.

(b) When notice of SSI termination is received, the local department of social services shall notify the person that redetermination is required to establish continuing eligibility and shall make the application available to him.

(c) When the written, signed application is received by the local department of social services, a new period under consideration will be set. The new period will be related to the date the application is received but may not include any months in which the person was entitled to coverage under the current certification period.

(d) The local department of social services shall notify the person or his representative of the required information and verifications needed to determine eligibility and the time standards in acting in the redetermination process.

(e) The local department of social services shall require the recipient or his representative to appear in person unless the local department of social services has determined that face-to-face contact is not necessary to make an accurate eligibility determination.

(f) All non-financial and financial factors for continuing eligibility shall be met.

(g) The following applies when the person is determined ineligible for Medical Assistance:

(i) When the SSI termination is received by the tenth day of the month, the local department of social services shall cancel certification effective the end of the month, unless the recipient requests a hearing in accordance with Regulation .13 of this chapter.

(ii) When the SSI termination notice is received after the tenth day of the month, the local department of social services shall cancel certification effective the end of the following month unless the recipient requests a hearing in accordance with Regulation .13 of this chapter.

(h) Notice of Eligibility Decisions.

(i) Eligible Persons. Persons who are determined eligible for a new period under consideration shall be sent notice in accordance with §A(1) of this regulation.

(ii) Ineligible Persons. Persons determined ineligible shall be sent notice in accordance with §A(2) of this regulation.

(i) When ineligibility is due to excess income only, the person will be provided with an explanation of the spend-down provision. Spend-down eligibility may be established at any time during the new period under consideration.

(2) Unscheduled Redetermination.

(a) The local department of social services shall promptly make unscheduled redetermination when:

(i) The person's circumstances suggest future changes which may affect eligibility before the due date of a scheduled redetermination;

(ii) Relevant facts or changes in circumstances are reported by the recipient or someone on his behalf; or

(iii) Relevant facts or changes are brought to the attention of the local department of social services from other responsible sources.

(b) The local department of social services shall notify the recipient that redetermination is required to establish continuing eligibility. Notification will be sent in a timely manner so that a decision of eligibility will be made within 30 days from the date of change.

(c) The local department of social services shall notify the recipient of the required information and verifications needed to determine eligibility and the time standards in acting in the redetermination process.

(d) The local department of social services shall require the recipient or his representative to appear in person unless the local department of social services has determined that a face-to-face contact is not necessary to make an accurate eligibility determination.

(e) All non-financial and financial factors for continuing eligibility shall be met.

(f) Eligibility Decisions.

(i) Eligibility Continued for the Remainder of the Certification Period. Recipients who are determined eligible for the remainder of the certification period will be sent notice in accordance with §A(1) of this regulation.

(ii) Recipients Determined Ineligible for the Remainder of the Certification Period. Recipients determined 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.

(g) A person may reapply at any time after the cancellation of current eligibility and a new period under consideration will be established.

(3) Scheduled Redetermination.

(a) The local department of social services shall make scheduled redeterminations at least once every 6 months for noninstitutionalized persons certified under Regulation .11B(3) of this chapter and at least once every 12 months for institutionalized persons certified under Regulation .11D(3) of this chapter.

(b) The local department of social services shall notify the recipient that redetermination is required to establish continuing eligibility. The notice and application will be sent at least 45 days before expiration of the current certification period.

(d) A recipient shall be treated the same as an applicant at the time of scheduled redetermination.

(e) All nonfinancial and financial factors of eligibility shall be met.

(f) The local department of social services shall make timely decisions in accordance with the provisions of Regulation .04I of this chapter.

(g) Eligibility Decisions.

(i) Eligibility Established. Applicants who are determined eligible for a new period under consideration shall be sent notice in accordance with §A(1) of this regulation.

(ii) Ineligibility Established. Applicants determined ineligible for the new period under consideration shall be sent notice in accordance with §A(2) of this regulation.

(h) When ineligibility is due to excess income only, the applicant will be provided with an explanation of the spend-down provision. Spend-down eligibility may be established at any time during the new period under consideration.

D. Subsequent Application. A person may reapply when eligibility is not met during the periods established in §C(1) and (3) of this regulation.

Md. Code Regs. 10.09.24.12

Regulation .12B amended effective August 8, 1988 (15:16 Md. R. 1914)
Regulations .12B amended as an emergency provision effective May 1, 1983 (10:11 Md. R. 962); adopted permanently effective September 1, 1983 (10:17 Md. R. 1521)
Regulations .12C amended effective May 1, 1986 (13:8 Md. R. 898)
Regulation .12C amended effective September 10, 1984 (11:18 Md. R. 1584)