Ala. Admin. Code r. 560-X-25-.04 - Application, Initial Determination Or Denial Of Eligibility, And Redetermination Of Eligibility
(1) An
application is a specific written request on the designated agency application
form which has been completed, dated and signed (including State acceptable
electronic signatures) by the applicant and/or applicant's representative or
guardian to have eligibility for categorical assistance determined. Application
is required before an individual may be determined eligible for Medicaid
benefits.
(2) Any person completing
an application for Medicaid benefits on behalf of another must have written
authority to do so. If the person being represented is unable to sign an
authorization, it must be signed by his or her legal guardian, if there is one,
or if there is none, then by his or her sponsor. A form entitled, "Appointment
of Representative," available from the Alabama Medicaid Agency must be
completed and signed by the applicant's representative. A copy of the form is
in Rule 560-X-28-.01(16)
of this code.
(3) A determination
of eligibility is the process by which the Medicaid Agency's worker obtains the
facts of the situation of the individual applying for Medicaid or Low-Income
Subsidy (LIS) as related to each factor of eligibility. In the eligibility
determination process, all facts and information related to eligibility which
are alleged by the applicant must be substantiated, verified, and
documented.
(4) A redetermination
of eligibility must be made by the Medicaid Agency, the Department of Human
Resources, Alabama Department of Public Health Child Health Insurance Program
(CHIP), or the Social Security Administration for every Medicaid or LIS
recipient at least once every twelve months. More frequent redeterminations are
necessary for recipients whose circumstances are likely to change or from whom
information indicates conditions have changed.
(5) When an applicant/recipient fails or
refuses to provide needed information within his/her capacity, he/she may be
denied or terminated from Medicaid or LIS; because eligibility cannot be
determined or redetermined.
(6)
Submission of an application for benefits containing a material misstatement, a
material omission, or a material false statement shall result in a denial or
termination of eligibility as appropriate, under such application for
reapplication.
(7) Any Medicaid
eligible child under age 19 who has been correctly determined Medicaid eligible
is deemed to be eligible for a total of 12 months regardless of changes in
circumstances other than attainment of the maximum age stated above, as long as
the child remains a resident of Alabama.
Notes
Authors: Denise Banks, Associate Director, Policy and Training, Beneficiary Services Division
Statutory Authority: Social Security Act, Titles XVI, XIX; Sections 1935(a), 1902(a) (66), 1860D-14, and 1905(p)(3); 20 CFR 416 ; 42 CFR 423.774 and 423.904, and 42 CFR 435.
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