Sec. 10.09.41.08. Determination, Notice, and Certification Period

A. Department's Determination. Based on the information presented, the Department shall determine whether an applicant or recipient is or is not eligible for the EID coverage group under this chapter.

B. Finding of Eligibility or Continuing Eligibility.

(1) Notice of Initial Eligibility. If the Department determines that an applicant is eligible, subject to the requirements of Regulation .07A of this chapter, for the EID coverage group, the Department shall issue to the applicant written notice that includes:

(a) A statement of the finding of eligibility, as applicable, indicating the beginning and ending dates of coverage, in accordance with §E of this regulation; and

(b) Notice of the right to request a hearing pursuant to Regulation .13 of this chapter.

(2) Notice of Continuing Eligibility. If the Department determines that a recipient qualifies for continuing eligibility for the EID coverage group, the Department shall issue to the recipient a written notice that includes:

(a) A statement of the finding of continuing eligibility, indicating the beginning and ending dates of coverage, in accordance with §E of this regulation; and

(b) A notice of the right to request a hearing pursuant to Regulation .13 of this chapter.

C. Denial or Termination.

(1) Applicant-Denial Notice. If the Department determines that an applicant is not eligible for the EID coverage group, the Department shall issue to the applicant a written denial notice that includes:

(a) A statement of the Department's finding for the EID coverage group;

(b) The reason for the finding;

(c) The regulation supporting the finding; and

(d) Notice of the right to request a hearing pursuant to Regulation .13 of this chapter.

(2) Recipient-Notice of Termination. If the Department finds that a recipient is no longer eligible for the EID coverage group, the Department shall issue to the recipient a written notice of termination that includes:

(a) A statement of the Department's finding that the recipient is no longer eligible for the EID coverage group;

(b) The reason for the finding;

(c) The regulation supporting the finding; and

(d) Notice of the right to request a hearing pursuant to Regulation .13 of this chapter.

D. Grounds for Department's Denial or Termination.

(1) If the Department finds one or more of the reasons for denial or termination listed in §D(2) of this regulation with respect to an applicant or recipient, the Department shall determine that:

(a) An applicant is not eligible for the EID coverage group and issue a notice of denial as specified in §C(1) of this regulation; or

(b) A recipient is no longer eligible for the EID coverage group and issue a notice of termination as specified in §C(2) of this regulation.

(2) Grounds for denial or termination from the EID coverage group shall include that an applicant or recipient:

(a) Does not meet, or no longer meets, the EID eligibility criteria for:

(i) Nonfinancial eligibility, as specified in Regulation .03 of this chapter; or

(ii) Financial eligibility, as specified in Regulation .04 of this chapter;

(b) Did not submit, within the time standard specified in Regulation .06B of this chapter:

(i) A complete application, signed by the applicant as required by Regulation .05A(3) of this chapter; and

(ii) All information and verifications requested by the Department pursuant to Regulation .05A(3)-(7) of this chapter, to determine the applicant’s or recipient’s eligibility for the EID coverage group;

(c) Did not cooperate with the Department’s eligibility determination process as required by Regulation .05A(9) of this chapter;

(d) Did not:

(i) Pay the premium required by Regulation .07A of this chapter; or

(ii) Submit a claim of hardship that was approved by the Department pursuant to Regulation .07C of this chapter;

(e) Did not comply with the posteligibility requirements specified in Regulation .09B and C of this chapter; or

(f) Died.

E. Certification Period.

(1) A recipient's certification period for initial eligibility shall begin on the first day of the month in which the Department receives the application.

(2) For a recipient approved by the Department for continuing eligibility, the next certification period shall begin on the first day of the month immediately following the month in which the previous certification period ends.

(3) Unless the recipient is terminated before the end of the certification period due to a change in circumstances or other reason for ineligibility, a recipient’s certification period ends, except as provided in §§D(2)(f) and E(4) of this regulation, on the last day of the current 12-month eligibility period.

(4) A recipient's certification period may be extended if the Department requires additional time to complete its redetermination of the recipient's eligibility.