TITLE 42 - PUBLIC HEALTH

CHAPTER IV - CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES

SUBCHAPTER C - MEDICAL ASSISTANCE PROGRAMS

PART 435 - ELIGIBILITY IN THE STATES, DISTRICT OF COLUMBIA, THE NORTHERN MARIANA ISLANDS, AND AMERICAN SAMOA

subpart j - ELIGIBILITY IN THE STATES AND DISTRICT OF COLUMBIA

435.911 - Timely determination of eligibility.

  (a) The agency must establish time standards for determining eligibility and inform the applicant of what they are. These standards may not exceed (1) Ninety days for applicants who apply for Medicaid on the basis of disability; and (2) Forty-five days for all other applicants.

  (b) The time standards must cover the period from the date of application to the date the agency mails notice of its decision to the applicant.

  (c) The agency must determine eligibility within the standards except in unusual circumstances, for example (1) When the agency cannot reach a decision because the applicant or an examining physician delays or fails to take a required action, or (2) When there is an administrative or other emergency beyond the agency's control.

  (d) The agency must document the reasons for delay in the applicant's case record.

  (e) The agency must not use the time standards (1) As a waiting period before determining eligibility; or (2) As a reason for denying eligibility (because it has not determined eligibility within the time standards).

[44 FR 17937, Mar. 23, 1979, as amended at 45 FR 24887, Apr. 11, 1980; 54 FR 50762, Dec. 11, 1989]