1. (a) An application for services shall include:

   1. (1) A fully completed and signed “Special Medical Services (SMS) – Application for All Services” (July 2023 Edition); and
   2. (2) A fully executed release to obtain medical records from the applicant’s physician, to confirm a chronic health condition.

2. (b) Within 60 days of the date of application, PIH shall:

   1. (1) Accept and review all applications for program eligibility, in accordance with He-M 523.05;
   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 Family Support Coordinator initiate phone contact to discuss the PIH program for which the applicant has been found eligible.

3. (c) PIH’s notice of decision shall include:

   1. (1) For eligibility approvals:

      1. a. The beginning and ending dates of PIH eligibility;
      2. b. The name and phone number of a PIH contact person; and
      3. c. Notice that the recipient shall report to PIH 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.
4. (d) 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 changes affect the recipient’s eligibility status.
5. (e) PIH 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 change which affects eligibility status.
6. (f) A new application shall be submitted in accordance with (a) above prior to the expiration of current eligibility.
7. (g) An applicant or recipient shall have the right to reapply at any time after eligibility has been denied.

8. (h) An applicant who submits false or misleading information shall be subject to the provisions of RSA 132:15 and RSA 638:15.

   Source. #7713, eff 6-21-02; ss by #9728, eff 6-18-10; ss by #12559, INTERIM, eff 6-26-18, EXPIRED: 12-24-18

   New. #12700, eff 12-28-18

   He-M 523. 05 Determination of Eligibility.

9. (a) The medical documentation provided pursuant to He-M 523.03 (b), and any other information provided by the applicant concerning the applicant’s unconfirmed chronic health condition, shall be the basis for determination of eligibility for services.
10. (b) A PIH coordinator shall review the medical documentation received regarding an applicant and, within 15 business days after the receipt of the documentation, confirm the applicant has a chronic health condition as defined by He-M 523.02(e).
11. (c) In cases where the information regarding eligibility is inconclusive, a SMS clinician shall make the determination of an applicant’s eligibility.

12. (d) If the information required to determine eligibility cannot be obtained or it is anticipated that the person will not be determined eligible in consultation with SMS within the timelines stated in (b) above, the PIH coordinator shall:

    1. (1) Request an extension from the applicant, in writing, stating the reason for the delay; and
    2. (2) Obtain the approval in writing from the applicant.
13. (e) Extensions approved in writing by the applicant in (d) above shall not exceed 30 business days after the receipt of the documentation.
14. (f) If the PIH coordinator’s request for an extension pursuant to (d) above is denied by the applicant, the PIH coordinator shall determine the applicant to be ineligible for services. The young adult or family may reapply for services pursuant to (k) below.
15. (g) The PIH coordinator shall authorize services to be provided prior to the completion of the eligibility determination process if such services are necessary to protect the health or safety of an applicant who the PIH coordinator believes is likely to be eligible, based upon available information.
16. (h) Within 5 business days of the determination of a family’s or a young adult’s eligibility, a PIH coordinator shall send notice to each applicant that includes the determination of eligibility.
17. (i) Preliminary planning to determine the services needed shall occur with the young adult or family when the application is submitted or no later than 5 business days from the notification of eligibility.
18. (j) Within 5 business days of determination of an applicant’s ineligibility, a PIH coordinator shall convey to the applicant a written decision that describes the specific legal and factual basis for the denial, including specific citation of the applicable law or department rule, and advise the applicant in writing and verbally of the appeal rights under He-M 523.13.
19. (k) Following denial of eligibility, the individual or family, as applicable, may reapply for services if new information regarding the diagnosis or about the health condition becomes available or if the timelines are not met in accordance with (f) above.
20. (l) The determination of eligibility by one PIH coordinator shall be accepted by every lead agency of the state.
21. (m) On an annual basis, the PIH coordinator shall re-determine the eligibility of a young adult or family through the review of the young adult’s or family’s action plan.
22. (n) Young adults and families shall make the necessary medical and other forms of documentation concerning the chronic health condition available upon request from the PIH coordinator, SMS or the lead agency.

Source. #7713, eff 6-21-02; ss by #9728, eff 6-18-10; ss by #12559, INTERIM, eff 6-26-18, EXPIRED: 12-24-18 New. #12700, eff 12-28-18 (formerly He-M 523.04)