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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.

Upon denial of eligibility (including suspension or termination of enrollment), a parent will be notified by mail of the reason for the denial and the process to notify CoverKids if the parent believes the denial is in error. Parents may also request a review for situations in which eligibility determination have not been made in a timely manner. Parents will first be directed to call the eligibility and enrollment TPA’s toll-free number and report additional information or clarify information on the applicant’s account. The TPA will document the call and any additional information/clarification provided. The family may also file a request for review in writing. The information or clarification will be input into the TPA eligibility system and a review of eligibility will be initiated. TPA eligibility staff may request senior management input into this decision. If the information provided does not result in the child being eligible, the parent will be notified of the reason the denial was upheld. If the parent disagrees with the denial, the notification letter will inform the parent that they may submit a formal request in writing to the Division of Insurance Administration, to be reviewed by the state-level CoverKids Eligibility Appeals Committee.

The member will have 30 days from the issuance of the letter to submit a request for a formal appeal. Receipts of requests for review will be acknowledged in writing within 10 days, including notification that that member will receive a decision within one calendar month. The Eligibility Appeals Committee is the impartial entity that reviews eligibility and enrollment matters and is composed of five Division of Insurance Administration staff. The Committee will meet weekly to review requests for reconsiderations of denials. (This schedule may be altered depending on the volume of requests for review.) If the Committee disagrees with the decision of the TPA, the child will be enrolled in CoverKids. If the Committee agrees with the decision to deny eligibility, a letter will be sent to the parent detailing the reason for denial. The decision of the Eligibility Appeals Committee will be the final recourse available to the member. If at any level of dispute, the appropriate party determines the child is eligible for enrollment in CoverKids, the enrollment will become effective retroactive to the first day of the month following the initial eligibility determination.

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