68.01 Notice of decision concerning eligibility115

In general. AHS will send timely notice of any decision affecting eligibility in accordance with federal and state laws. Any notice issued by a QHP issuer is not a notice of decision. In general, a notice of a decision that adversely affects an enrollee’s eligibility will be sent in advance of its effective date. A notice of a decision that adversely affects a Medicaid enrollee’s eligibility, including a notice of termination, reduction, suspension of eligibility, or increase in liability, will comply with the advance notice requirements under § 68.02. (b) Content of eligibility notice In general. Any notice of decision will contain clear statements of the following: (i) AHS’s decision and its basis; (ii) The effective date of the decision, if applicable; (iii) The specific reasons supporting the decision; (iv) The specific regulations that support, or the change in federal or state law that requires, the 115 42 CFR § 435.917; 45 CFR §§ 155.310(g) and 155.355. Eligibility-and-Enrollment Procedures Part 7 – Page 53 (Sec.68.00, Sub.68.01) decision; (v) An explanation of the individual’s appeal rights, including the right to request a fair hearing and an explanation of the circumstances under which the individual has the right to an expedited administrative appeal pursuant to § 80.07; (vi) A description of the methods by which the individual may appeal; (vii) The time frame in which AHS must make a final administrative decision in a fair hearing and an expedited administrative appeal; (viii) Information on the individual’s right to represent themselves at a fair hearing or use legal counsel, a relative, a friend or other spokesperson; (ix) In cases of a decision based on a change in law, an explanation of the circumstances under which a fair hearing will be granted; (x) An explanation of the circumstances under which the individual’s eligibility for QHP, APTC or CSR or their Medicaid will be continued pending a fair hearing decision; and (xi) In connection with eligibility for a QHP, an explanation that a fair hearing decision for one household member may result in a change in eligibility for other household members and that change may be handled as a redetermination. Notice of approved eligibility. In addition to the information in paragraph (b)(1) of this subsection, a notice of approval of eligibility will contain clear statements of the following: (i) The basis and effective date of the eligibility; (ii) The circumstances under which the individual must report, and the methods for reporting, any changes that may affect their eligibility; (iii) For an individual approved for Medicaid, basic information on the level of Medicaid benefits and services approved, including, if applicable, a description of any premiums and cost-sharing required, an explanation of how to request additional detailed information on benefits and financial responsibility, and the right to appeal the level of benefits and services approved; and (iv) For an individual approved for Medicaid subject to a spenddown, the amount of medical expenses which must be incurred to establish eligibility. Medicaid notices of decision based on income at or below MAGI-based standard.116 Whenever an approval, denial or termination of eligibility is based on an individual having a household income at or below the applicable MAGI-based income standard, the eligibility notice will contain clear statements of the following: (i) Information regarding bases of eligibility other than the MAGI-based income standard and the 116 42 CFR § 435.917(c). Eligibility-and-Enrollment Procedures Part 7 – Page 54 (Sec.68.00, Sub.68.02) benefits and services available to individuals eligible on such other bases, sufficient to enable the individual to make an informed choice as to whether to request a determination on such other bases; and (ii) Information on how to request a determination on such other bases. (c) Timing of notification of appeal rights.117 AHS will provide notice of appeal rights as described in paragraph (b)(1) of this subsection: At the time that the individual applies for health benefits; and At the time AHS makes a decision affecting the individual’s eligibility.