37.82.204 DETERMINATION OF ELIGIBILITY
(1) Timely determination of eligibility:
(a) Aid will be furnished in a timely manner to eligible persons and will conform to the following time standards:
(i) 90 days for applicants on the basis of disability; and
(ii) 45 days for all other applicants.
(b) These time standards cover the period from the date of application to the date the department mails or otherwise provides the applicant with a formal written notice of decision.
(c) Eligibility will be determined within the time standards except in cases of unusual circumstances which are caused by the claimant or which are beyond the department's control.
(d) The time standards will not be used:
(i) as a waiting period before determining and announcing eligibility; or
(ii) as a reason for denying eligibility because it has not been determined within the time standard.
(2) Denials or determinations of disability made by the U.S. social security administration (SSA) will be accepted by the department unless one of the following conditions exist:
(a) the individual has not applied to SSA for supplemental security income (SSI) cash benefits, or is found ineligible for SSI for a reason other than a disability;
(b) the individual has applied both to SSA for SSI and to the department for medicaid, but SSA has not made a disability determination within 90 days from the date of the individual's application for medicaid; or
(c) the individual has applied for medicaid as a non-cash recipient; and
(i) alleges a disabling condition different from, or in addition to that considered by SSA in making its determination; or alleges more than 12 months after the most recent SSA determination denying disability that his condition has changed or deteriorated since that SSA determination and further alleges a new period of disability which meets the durational requirements of the Social Security Act, and has not applied to SSA for a determination with respect to these allegations; or
(ii) alleges less than 12 months after the most recent SSA determination denying disability that his condition has changed or deteriorated since that SSA determination, alleges a new period of disability which meets the durational requirements of the Social Security Act and has applied to SSA for reconsideration or reopening of its disability decision and SSA refused to consider the new allegations.
(3) Determinations of disability will be made in accordance with the requirements applicable to disability determinations under the Supplemental Security Income Program specified in 20 CFR, part 416, subpart I (1993) . The department hereby adopts and incorporates by reference 20 CFR, part 416, subpart I (1993) . A copy of these federal regulations may be obtained from the Department of Public Health and Human Services, Developmental Disabilities Program, 111 Sanders, P.O. Box 4210, Helena, MT 59604-4210.
(4) If the department bases its disability determination upon the decision made by the social security administration (SSA) the medicaid applicant is limited to appealing the decision through the SSA procedures for hearing and appeals. If the department makes a decision of disability on its own as set forth under the circumstances stated in (2) of this rule, the medicaid applicant has a right of appeal through the department's fair hearing process.
(5) Adequate notice:
(a) Each applicant will be sent a written notice of the department's decision on his application.
(b) If eligibility is denied, written notice will include the reasons for the action, the specific regulation or statute supporting the action, and an explanation of the applicant's right to request a hearing and will be mailed or otherwise provided to the applicant no later than date of denial.
(6) Disposal of applications:
(a) Each application will be disposed of by a finding of eligibility or ineligibility, unless:
(i) the applicant voluntarily withdraws his application;
(ii) the applicant dies and no one acting responsibly on his behalf requests in writing to have the application continued; or
(iii) the applicant cannot be located.
(b) Voluntary withholding of information that is mandatory for eligibility determination by the applicant will result in a finding of ineligibility.
(7) Effective date:
(a) Eligibility for medicaid will be effective as provided below, if the individual was or if he had applied would have been eligible for medicaid.
(i) "if he had applied" includes if someone had applied for him; also, the individual need not be alive when application for medicaid is made on his behalf.
(b) For coverage of aged, blind and disabled persons whose eligibility is related to the supplemental security income program, eligibility is granted for the month provided the resource eligibility criteria is met the first moment of the first day of that month and all other eligibility criteria are met for that month.
(c) For coverage of parents and children whose eligibility is related to the FAIM financial assistance program, eligibility is granted for the month if all eligibility criteria are met on the date of application and first day of subsequent month.
(d) For coverage of medically needy persons, eligibility begins:
(i) on the first of the month when the medically needy person pays the cost-share amount as defined in ARM 37.82.1107; or
(ii) when incurred remedial and medical expenses equal the required incurment as defined in ARM 37.82.1107 for the period.
(e) In no case will coverage be granted prior to the first day of the third month preceding the date of application.
History: Sec. 53-6-113, MCA; IMP, Sec. 53-6-131, 53-6-132 and 53-6-133, MCA; NEW, 1982 MAR p. 729, Eff. 4/16/82; AMD, 1985 MAR p. 181, Eff. 2/15/85; AMD, 1986 MAR p. 678, Eff. 4/25/86; AMD, 1993 MAR p. 1398, Eff. 7/1/93; AMD, 1994 MAR p. 36, Eff. 1/14/94; AMD, 1998 MAR p. 3281, Eff. 12/18/98; TRANS, from SRS, 2000 MAR p. 476.