Department of Human Services: 4.6 through 4.7

IMA POLICY MANUAL
PART VII: SPECIAL MA PROCESSING

CHAPTER 4: DC HEALTHCARE ALLIANCE PROGRAM

CASE MAINTENANCE 4.6

Recertification 4.6.1

Alliance program recipients must recertify for benefits every six (6) months. Recertifications will be completed in compliance with the policies and procedures detailed in Part VIII: Chapter 4: Recertification, with the following additional requirements:

· Persons who are recertifying for Alliance benefits must complete a face-to-face interview as part of the recertification process. The recertification form will not be considered complete until this requirement is satisfied. Persons may request a waiver of this requirement due to being hospitalized, disabled or elderly (for documentation needed to support a waiver request, see Section 4.5.2a: Application Review in this Chapter). For a recertification interview waiver request, the documentation must state that the person recertifying is not available and will not be available for the period beginning from the date the recertification form is mailed through the last day of the certification period.

· Persons who are recertifying for Alliance benefits must verify all of the following:

o DC residence

o All income of the Alliance enrollee and spouse, if any

o All resources of the Alliance enrollee and spouse, if any

· US citizens must provide a valid and verifiable Social Security number, if not already provided and ver verified

· Qualified aliens must provide a valid nine-digit alien number, if not already provided.

If the recipient provides all information needed to re-determine eligibility, confirming that s/he continues to meet all financial and nonfinancial eligibility requirements, the SSR will recertify Alliance benefits for an additional six months.

Reporting Changes 4.6.2

Alliance program recipients must report changes that affect their eligibility for benefits by the 10th day of the month following the month of the change. If the group reports an additional group member, the SSR will make the change for the month of the change, if otherwise eligible. If the group reports that a group member has left or that a change has occurred that makes the group ineligible, the SSR will make the change for the month following expiration of adequate and timely notice.

A person who fails to report a change timely may lose his/her benefits and face civil and criminal penalties.

When an Alliance enrollee requests that a spouse be added to the case, and the spouse would be eligible for the Alliance, the spouse must complete a face-to-face interview, or request a waiver from the requirement.

Case Termination 4.6.3

If the recipient fails to complete all steps in the Alliance recertification process (see Section 4.6.1: Recertification in this Part), the SSR must send timely and adequate notice of the agency's intent to terminate Alliance benefits. If the recipient does not respond within 15 days, the SSR should terminate the Alliance benefits for the next available month.

If the recipient reports (and verifies when necessary) a change at Alliance recertification that results in termination of Alliance benefits and affects the person's eligibility for other program benefits also, the SSR should re-evaluate his/her eligibility for those programs.

Notices of Alliance program termination must meet all requirements listed in Part VIII: Chapter 10, Case Maintenance, Notice of Adverse Action.

Shortened Certification Period 4.6.3a

Effective September 27, 2011, persons who were approved for a twelve-month certification period at application or recertification may be required to comply with the following requirements:

· Participate in a face-to-face interview, unless the requirement is waived;

· Verify residence, income, and resources;

· For U.S. citizens, provide a valid and verifiable Social Security number, if not already provided; and

· For Qualified Aliens, provide a valid and verifiable Social Security number and a nine-digit Alien Number, if not already provided.

The Agency will send at least thirty days’ advance notice of the requirement to comply with the new requirements for persons certified under the prior rules.

Persons who comply with the new requirements and are determined to be eligible will have their certification period shortened to end on the sooner of the following dates:

• Six months from the month the recipient complies with the new requirements, or

• Twelve months from the original determination, if there are less than six months remaining in the certification period.

Persons who do not comply, or who do comply and are determined to be ineligible for the Alliance, will be terminated after timely and adequate notice.

Fair Hearings 4.6.4

An applicant/recipient dissatisfied with an action taken by the Department which affects Alliance benefits, participation or requirements can request a fair hearing. The hearing process outlined in Part VIII: Chapter 7, Case Maintenance: Grievances and Fair Hearings should be used.

Fraud in Obtaining Benefits 4.6.5

An applicant, or his/her authorized representative, must give true, accurate and complete documents and information. A person who gives false, deceptive or misleading documents or information may lose his/her benefits and face civil and criminal penalties.

Non-cooperation in Eligibility Review 4.6.6

An applicant and his/her authorized representative must cooperate with District investigators and their duly authorized agents who review the applicant’s eligibility record. The requirement for cooperation includes being interviewed by investigators, but the applicant may still refuse entry in his/her home. An applicant who fails to cooperate may lose his/her benefits. An applicant and his/her authorized representative may face civil and criminal penalties.

VERIFICATION 4.7

Except where noted earlier, the SSR should use standard verification procedures to verify financial and nonfinancial eligibility requirements.

< Previous Section

<< Back to Table of Contents