1. (a) Good cause shall include, but not be limited to, the following circumstances:

   1. (1) The beneficiary experiences the birth or death of a family member residing with the beneficiary;
   2. (2) The beneficiary experiences severe inclement weather, including a natural disaster, and was unable to meet the requirement;
   3. (3) The beneficiary has a family emergency or other life-changing event such as divorce;
   4. (4) The beneficiary is a victim of domestic violence, dating violence, sexual assault or stalking;
   5. (5) The beneficiary is a custodial parent or caretaker of a child 6 to 12 years of age who, as determined by the commissioner on a monthly basis, is unable to secure child care in order to participate in community engagement activities either due to a lack of child care scholarship or the inability to obtain a child care provider due to capacity, distance, or another related factor;
   6. (6) The beneficiary has a disability, and was unable to meet the community engagement requirement for reasons related to that disability;
   7. (7) The beneficiary resides with an immediate family member who has a disability, and was unable to meet the community engagement requirement for reasons related to the family member’s disability, but did not request an exemption from the community engagement requirement;
   8. (8) The beneficiary experienced a hospitalization, but did not request an exemption from the community engagement requirement;
   9. (9) The beneficiary resides with an immediate family member who experienced a hospitalization or serious illness, but the beneficiary did not request an exemption from the community engagement requirement;
   10. (10) The beneficiary is homeless; or
   11. (11) Other good cause exists, such as circumstances beyond the beneficiary’s control which related to the beneficiary’s ability to obtain or retain a qualifying community engagement activity. Other good cause shall include an illness that did not require inpatient hospitalization.
2. (b) All beneficiaries requesting a finding of good cause shall complete and submit BFA Form 340 “Good Cause Request Form - Granite Advantage Health Care Program” (04/19) along with any required third party certification(s) to the department.

3. (c) Beneficiaries requiring certification by licensed medical professional for good cause in (d) below shall have the licensed medical professional certify on BFA Form 340 “Good Cause Request Form. Granite Advantage Health Care Program” (06/19) as follows:

   “A showing of good cause for “disability” or “Caretaker residing with immediate family member with disability” requires certification by a licensed medical professional. As a licensed medical professional caring for this beneficiary or for a beneficiary’s family member with a disability, I hereby certify that: The beneficiary is disabled and unable to meet the community engagement requirement for reasons related to their disability; or the family member identified above is disabled.”

4. (d) A beneficiary’s request for a finding of good cause shall be attested to and certified as follows:

   1. (1) For a beneficiary who experiences the birth or death of a family member residing with the beneficiary, attestation by the beneficiary of the event to include the name of the family member, the date of the event, the family member’s relationship to the beneficiary, and the number of days impacted;
   2. (2) For a beneficiary who experiences severe inclement weather, including a natural disaster, and therefore was unable to meet the requirement, attestation by the beneficiary of the date(s) of the severe inclement weather or natural disaster, and the number of days impacted;
   3. (3) For a beneficiary who has a family emergency or other life-changing event such as divorce, attestation by the beneficiary of the nature of the family emergency or life-changing event to include the date(s) and the number of days that the beneficiary was unable to participate due to the circumstance;
   4. (4) For a beneficiary who is a victim of domestic violence, dating violence, sexual assault, or stalking, documentation of the date range specified in the court order or self-attestation to the number of days impacted;
   5. (5) For custodial parents as described in (a)(5) above, a monthly attestation by the beneficiary of the inability to secure child care and the number of days impacted;

   6. (6) For a beneficiary who has a disability, , and was unable to meet the requirement for reasons related to that disability the following shall be required:

      1. a. Attestation by the beneficiary of the number of days the beneficiary was unable to meet the community engagement requirement for reasons related to the disability; and
      2. b. The certification described in (c) above;

   7. (7) For a beneficiary who resides with an immediate family member who has a disability, and was unable to meet the requirement for reasons related to the family member’s disability, but did not request an exemption from the community engagement requirement, the following shall be required:

      1. a. Attestation by the beneficiary of the number of days the beneficiary was unable to meet the community engagement requirement for reasons related to that disability; and
      2. b. The certification described in (c) above;

   8. (8) For a beneficiary who experienced a hospitalization, but did not request an exemption from community engagement requirement, the following shall be required:

      1. a. Attestation by the beneficiary of the number of days of the hospitalization and the admission date; and
      2. b. Copies of the discharge summaries, or financial or billing information that would substantiate the hospitalization or certification by a licensed medical professional;

   9. (9) For a beneficiary who resides with an immediate family member who experienced a hospitalization or serious illness, but the beneficiary did not request an exemption from community engagement requirement, the following shall be required:

      1. a. Attestation by the beneficiary of the number of days of the hospitalization or serious illness or certification by a licensed medical professional; and
      2. b. Copies of the family member’s discharge summary, or financial or billing information, or other medical records that would substantiate the hospitalization or serious illness;
   10. (10) For a beneficiary who is homeless, attestation by the beneficiary of the beneficiary’s homelessness or inability to find stable housing and the number of days the beneficiary was unable to meet the community engagement requirement; or
   11. (11) For a beneficiary to claim other good cause under (a)(11), attestation by the beneficiary of the circumstance beyond the beneficiary’s control which relate to the beneficiary’s ability to obtain or retain a community engagement activity to participate in, and the number of days the beneficiary was unable to meet the community engagement requirement.
5. (e) A request for a finding of good cause under this section shall not be approved unless the required attestation(s) and certification(s) are received by the department.
6. (f) The department shall use the documentation received to determine if the community engagement requirement would have been met if not for the good cause.

Source. #12733, INTERIM, eff 2-23-19, EXPIRES: 8-22-19; ss by #12796, eff 6-5-19 (formerly He-W 837.11); BFA form 340 in (c) amd by #12828