1. (a) In order to be determined eligible to receive program services or financial assistance, a signed, dated, and completed application, entitled “Bureau for Family Centered Services (BFCS),” (July 2023) shall be submitted to SMS for each applicant.

2. (b) The following documentation shall accompany the submitted application in (a) above:

   1. (1) Supporting documentation of income and resources, as applicable;
   2. (2) Supporting documentation regarding the applicant’s health diagnosis;
   3. (3) A signed release of personal health information, which complies with current Health Insurance Portability and Accountability Act (HIPPA) policies as defined in 45 CFR 160.103 and 45 CFR 164.501; and
   4. (4) Documentation of guardianship of an applicant or foster parent status, as applicable.

3. (c) Within 60 days of the date of application, SMS shall:

   1. (1) Accept and review all applications for program or financial eligibility, in accordance with He-M 520.03 and He-M 520.05;
   2. (2) Notify the applicant in writing of the applicant’s eligibility status and the services for which the applicant is eligible; and
   3. (3) Have the applicable Program Coordinator(s) initiate phone contact to discuss the SMS program(s) for which the applicant has been found eligible.

4. (d) SMS’s notice of decision shall include:

   1. (1) For eligibility approvals:

      1. a. The beginning and ending dates of SMS eligibility;
      2. b. The approved SMS services;
      3. c. The name and phone number of an SMS contact person;
      4. d. Financial eligibility determination, including the spend down amount, as applicable; and
      5. e. Notice that the recipient shall report to SMS any change in the recipient’s medical insurance coverage, including Medicaid or TPL changes, within 30 days of the change; and

   2. (2) For eligibility denials:

      1. a. The reason(s) for denial;
      2. b. Information about the applicant’s right to an appeal in accordance with He-M 202 and He-C 200; and
      3. c. Alternate support services information as available.
5. (e) For an applicant who is determined to be eligible, eligibility shall be effective for 12 months from the applicant’s application date, except when any household changes affect the recipient’s eligibility status.
6. (f) SMS shall notify a recipient in writing 30 calendar days prior to the date that eligibility will close, for such reasons as the 12-month eligibility period is expiring, the recipient is turning 21, services provided are no longer available, or there is a household change which affects eligibility status.
7. (g) A new application shall be submitted in accordance with (a) and (b) above prior to the expiration of current eligibility.
8. (h) An applicant or recipient shall have the right to reapply at any time after eligibility has been denied.
9. (i) An applicant who submits false or misleading information shall be subject to the provisions of RSA 132:15 and RSA 638:15.

Source. #9748-A, eff 7-1-10, para (c)-(h), intro., & (i)(1), (4), & (5), and (j); #9748-B, eff 7-1-10, paras (a), (b), and (i)(3); amd by #10138, eff 7-1-12; ss by #12558, INTERIM, eff 6-26-18, EXPIRED: 12-24-18 New. #12699, eff 12-28-18; (see also Revision Note at part heading for He-M 520)