Sec. 10.11.03.04. Rights and Responsibilities

A. Applicant.

(1) The applicant shall furnish factual information regarding the applicant’s eligibility, and shall keep the CMS Program informed of any change in demographic, financial, medical, or insurance coverage status.

(2) An eligible applicant shall use only Medical Assistance approved providers.

(3) An applicant shall complete a Medical Assistance application when the applicant is considered potentially eligible.

B. CMS Program.

(1) An applicant who meets eligibility criteria as set forth in this chapter shall have access to approved services within the budgetary limitations of the CMS Program.

(2) The CMS Program may purchase health insurance benefits for an eligible child when all of the following conditions are met:

(a) The cost of this expense is less than the cost of directly purchasing the child’s medical care;

(b) The policyholder is unable to pay for the health insurance policy due to:

(i) An increase in insurance cost;

(ii) A change in employment;

(iii) Loss of income;

(iv) An increase in health-related expenses; or

(v) The policyholder’s eligibility to purchase health insurance benefits in accordance with the Consolidated Omnibus Budget Reconciliations Act of 1985, P.L. 99-272;

(c) The health insurance policy is issued directly from:

(i) An authorized insurer;

(ii) A nonprofit health services plan;

(iii) A health maintenance organization;

(iv) A self-insured health benefit plan; or

(v) The employer of the family member whose health insurance provides coverage for the eligible child; and

(d) Payment is for premiums that can be costed out as related to the applicant only.

(3) The CMS Program may pay copays, deductibles, and coinsurance costs when the CMS Program is purchasing the health insurance benefits.

(4) The CMS Program shall comply with the requirements of:

(a) Title VI of the Civil Rights Act of 1964 as amended;

(b) The Age Discrimination Act of 1975 as amended;

(c) Section 504 of the Rehabilitation Act of 1973 as amended; and

(d) The Americans with Disabilities Act of 1989.

(5) The CMS Program shall determine financial assistance based on the income and allowable deductions.

(6) The CMS Program shall provide full financial assistance for authorized services when the income is equal to or less than that which is allowable in accordance with the financial eligibility levels described in Regulation .05A(4) of this chapter.

(7) The CMS Program shall provide full CMS Program eligible service to the extent that medical assistance for this service is not covered under Title XIX.