18.04 Good cause for noncooperation

In general. An individual who is applying for or enrolled in Medicaid may request a waiver of the cooperation requirement under § 18.03. Those to whom a good-cause waiver for noncooperation has been granted are eligible for Medicaid, provided that all other program requirements are met. AHS will grant such waivers when either of the following circumstances has been substantiated to AHS’s satisfaction: (1) Compliance with the cooperation requirement is reasonably anticipated to result in physical or emotional harm to the individual responsible for cooperating or the person for whom medical support or third-party payments are sought. Emotional harm means an emotional impairment that substantially affects an individual’s functioning; or (2) Compliance with the cooperation requirement would entail pursuit of medical support for a child: (i) Conceived as a result of incest or rape from the father of that child; (ii) For whom adoption proceedings are pending; or (iii) For whom adoptive placement is under active consideration. Required documentation. An Individual requesting a waiver of the cooperation requirement bears the primary Nonfinancial eligibility requirements Part 3 – Page 12 (Sec.19.00, Sub.0) responsibility for providing the documentation AHS deems necessary to substantiate their claims of good cause. AHS will consider an individual who has requested a good-cause waiver and submitted the required documentation to be eligible for Medicaid while a decision on the request is pending. Review of good-cause waiver. A review of the continued existence of good cause circumstances upon which a waiver has been granted is required no less frequently than at each redetermination of eligibility for those cases in which determination of good cause is based on a circumstance that may change. A formal decision based upon resubmission of evidence is not required, however, unless AHS determines that a significant change of circumstances relative to good cause has occurred.