R414-310-11. Eligibility Decisions and Reviews

  (1) The Department adopts and incorporates by reference 42 CFR 435.911 and 435.912, October 1, 2013 ed., regarding eligibility determinations.

  (2) At application and review, the eligibility agency shall determine whether the individual is eligible for Medicaid, Refugee Medical or CHIP.

  (a) An individual who qualifies for Medicaid or Refugee Medical without paying a spenddown or for Medicaid Work Incentive (MWI) without paying an MWI premium may not enroll in PCN.

  (b) An applicant who is eligible for Medicaid, Refugee Medical or CHIP during the application month, or a Medicaid, Refugee Medical or CHIP recipient who requests PCN enrollment during an open enrollment period, may enroll in PCN in accordance with Subsection R414-310-12(1).

  (3) An individual open on Medicaid, Refugee Medical or UPP may request to enroll in PCN.

  (a) A new application form is not required.

  (b) The rules in Section R414-310-12 govern the effective date of enrollment.

  (c) If the individual is moving from UPP, the eligibility agency shall waive the open enrollment requirement if there is no break in coverage.

  (d) If the individual is moving from Medicaid or Refugee Medical, the eligibility agency shall waive the open enrollment period if the individual was previously on PCN, became eligible for Medicaid or Refugee Medical, and requests to reenroll in PCN without a break in coverage.

  (e) If the individual is moving from Medicaid or Refugee Medical and was not previously on PCN, or there has been a break in coverage of one or more months, the individual must reapply during an open enrollment period.

  (f) All other eligibility requirements must be met.

  (4) The eligibility agency shall complete an eligibility determination for each application unless:

  (a) the applicant voluntarily withdraws the application and the eligibility agency sends a notice to the applicant to confirm the withdrawal;

  (b) the applicant dies;

  (c) the applicant cannot be located; or

  (d) the applicant does not respond to requests for information within the 30-day application period or by the verification due date, if the verification date is later.

  (5) The eligibility agency shall complete a periodic review of an enrollee's eligibility for medical assistance in accordance with the requirements of 42 CFR 435.916.

  (a) The agency may request a recipient to contact the agency to complete the eligibility review.

  (b) The agency shall provide the recipient a written request for verification needed to complete the review.

  (c) The agency shall provide proper notice of an adverse decision.

  (d) If the agency cannot provide proper notice of an adverse decision, the agency extends eligibility to the following month to allow for proper notice.

  (6) If a recipient fails to respond to a request to complete the review or fails to provide all requested verification to complete the review, the eligibility agency shall end eligibility effective the end of the month for which the agency sends proper notice to the recipient.

  (a) If the recipient contacts the agency to complete the review or returns all requested verification within three calendar months of the closure date, the eligibility agency shall treat such contact or receipt of verification as a new application. The agency may not require a new application form.

  (b) The application processing period applies to this request to reapply.

  (c) Eligibility can begin in the month the client contacts the agency to complete the review if all verification is received within the application processing period.

  (d) If the recipient fails to return the verification timely, but before the end of the three calendar months, eligibility becomes effective the first day of the month in which all verification is provided and the individual is found eligible.

  (e) The eligibility agency may not continue eligibility while it makes a new eligibility determination.

  (f) The eligibility agency shall waive the open enrollment requirement during these three calendar months.

  (g) If the enrollee does not respond to the request to complete the review for PCN during the three calendar months immediately following the review closure date, the enrollee must reapply for PCN and meet all eligibility criteria.

  (7) If the individual files a new application or makes a request to reenroll within the calendar month that follows the effective closure date when the closure is for a reason other than incomplete review, the eligibility agency shall waive the open enrollment period and process the request as a new application.

  (8) The enrollee must reapply if the case closes for one or more calendar months for any reason other than an incomplete review.

  (9) The eligibility agency shall comply with the requirements of 42 CFR 435.1200(e), regarding transfer of the electronic file for the purpose of determining eligibility for other insurance affordability programs.