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11.2.5. Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6. Section 1128E (relating to the National health care fraud and abuse data collection program) Section 12. Applicant and enrollee protections (Sections 2101(a)) Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan. Eligibility and Enrollment Matters 12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120. Described below is a description of California’s review process for eligibility and enrollment matters that complies with 42 CFR 457.1120. These processes reflect those in the Healthy Families Program and C-CHIP. a) As required in 42 CFR 457.1130(a), California provides applicants and enrollees the opportunity to review eligibility and enrollment issues such as denial of eligibility; failure to make a timely determination of eligibility; and suspension or termination of enrollment, including disenrollment for failure to pay cost sharing. These eligibility and enrollment issues are specifically included in the Healthy Families regulations, program handbook, and notification letters to applicants and enrollees. All decisions are provided in writing and all decisions which have a negative impact on an applicant or enrollee include instructions on how to appeal the decision if the applicant or enrollee believes the decision is incorrect. b) For purposes of implementing 42 CFR 457.1170 California has determined that the first level appeal review conducted by the Appeals Unit within the administrative vendor meets the core requirements as defined in 42 CFR 457.1150(a) as an impartial review. The Appeals Unit is a distinct and separate unit from the Eligibility Unit that makes the initial eligibility determination and is not directly involved in the matter under review. Effective Date: Approval Date: November 1, 2009 HFP Family Contribution Increase November 1, 2009 HFP Co-Payment Increase November 1, 2009 HFP Limited Dental Plan Choice for New Subscribers

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