Sec. 10.09.43.15. Post-Eligibility Requirements

A. Notice of Eligibility Determination. The Department or its designee shall inform the applicant of the applicant's legal rights and obligations and give the applicant written or electronic notification of the following:

(1) For eligible individuals:

(a) The basis and effective date for eligibility;

(b) Instructions for reporting changes that may affect the recipient’s eligibility; and

(c) The right to request a hearing; and

(2) For ineligible individuals:

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

(b) Information regarding application for MAGI excluded coverage groups; and

(c) The right to request a hearing.

B. Applicant Responsibility.

(1) The applicant shall notify the Department within 10 working days of changes affecting the applicant’s eligibility.

(2) Only an applicant that has been determined eligible by the Department or its designee shall use MCHP Premium benefits.

(3) If written or electronic notice of cancellation is received, the applicant shall discontinue use of MCHP Premium benefits on the first day of ineligibility.

(4) Failure to comply with the provisions of §B(1)-(3) of this regulation may result in:

(a) The termination of assistance; or

(b) Referral to the Department for fraud investigation, or for criminal or civil prosecution.

(5) The applicant shall cooperate with the Department’s quality control review process, including verification of all information pertinent to the determination of eligibility.

(6) If the applicant refuses to cooperate, the applicant’s coverage shall be terminated.

C. Unscheduled Redetermination.

(1) The Department shall:

(a) Promptly make an unscheduled redetermination of a recipient's eligibility if changes in circumstances or relevant facts are:

(i) Reported by someone on the applicant’s behalf; or

(ii) Brought to the attention of the Department from other responsible sources; and

(b) Notify the applicant of the required information and verifications needed to determine eligibility and the time standards in acting in the redetermination process.

(2) Eligibility Decisions. Recipients who are determined:

(a) Eligible for the remainder of the certification period shall be sent notice in accordance with §A(1) of this regulation; or

(b) 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.

(3) A recipient whose eligibility has been canceled may reapply for MCHP at any time.

D. Scheduled Redetermination.

(1) Redetermination is required to establish continued eligibility.

(2) Redetermination shall be scheduled annually.

(3) Completion of the application and determination of eligibility for MCHP by the Department or its designee is required for renewal for program eligibility.