Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-25 - MEDICAID ELIGIBILITY › Section 560-X-25-.04 - Application, Initial Determination Or Denial Of Eligibility, And Redetermination Of Eligibility

Current through Register Vol. 42, No. 9, June 28, 2024
(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.
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.