Page 53

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

53

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.

Pennsylvania implemented an Eligibility Review Process on July 1, 2001. An eligibility review may be requested when:

• an applicant is denied coverage • an enrollee’s coverage is to be terminated

• an enrollee’s coverage is to change from Free Health Care Insurance to Subsidized Health Care Insurance • an enrollee’s coverage is to move from a lower premium rate to a higher premium rate within the subsidized program or coverage is moved to the at cost program • an enrollee’s coverage is to move from a higher premium rate to a lower premium rate, but the enrollee disagrees with the determination (mistake in calculating income or family size) or states that they should be in the free program or Medicaid • there is a failure to make a timely determination of eligibility

The parent or guardian of an applicant or an enrollee may request a review within 30 days of the date of the notice of ineligibility, termination or change in coverage. A request for a review is sent to the Pennsylvania Insurance Department.

Notices to the parent or guardian must include information concerning the impartial eligibility review process. Whenever possible, disputes related to eligibility are resolved prior to the conduct of the review by the Department.

When a request for an impartial review is received, the Department:

• Logs in the request for a review • Determines the need for expedited review (i.e. the parent or guardian has indicated that the child has an immediate need for medical attention) • Informs the Contractor that a request for review has been received • Informs the Contractor that coverage should continue or be reinstated until the review process has been concluded • Requests that the contractor forward to the Review Officer a copy of