Common use of Eligibility Procedures Clause in Contracts

Eligibility Procedures. The conference agreement requires the Secretary to establish procedures for eligibility determinations for endorsed programs and for those eligible as a transitional assistance eligible individual or a special transitional eligible individual. The Secretary is to define the terms income and family size and specify the methods and period for which they are determined. If such methods provide for use of information for prior time periods, the Secretary is required to permit an individual whose circumstances changed to have eligibility for transitional assistance determined for a more recent period. The Secretary may use a reconsideration process or other method. An individual wishing to be treated as a transitional assistance eligible individual or special transitional eligible individual could self-certify through a simplified means as to their income, family size, and prescription drug coverage (if any). The certification could also be done by another qualified person, acting on the individual’s behalf. The certification could be provided before, on or after the time of enrollment in an endorsed program. The self- certification would be deemed as consent to have the information verified by the Secretary. A verified self-certification for as a transitional assistance or special transitional assistance eligible individual would be applicable for the entire period of enrollment in any endorsed program. The Secretary is required to establish verification methods, which could include sampling and use of information on Medicaid eligibility provided by the states, financial information from the Commissioner of Social Security, and financial information from the Secretary of the Treasury. The Secretary could find that an individual met the income requirements for transitional assistance if the individual is within a category of discount card eligible individuals who are enrolled under Medicaid (such as qualified Medicare beneficiaries, specified low- income Medicare beneficiaries, and certain qualified individuals). States will be required, as a condition of Federal Medicaid assistance to provide, on a timely basis, information that allows the Secretary to identify persons eligible for drug coverage under Medicaid, or who are transitional assistance eligible individuals, or special transitional eligible individuals. The Secretary is required to establish a reconsideration process for persons determined not to be transitional eligible or special transitional assistance eligible individuals. The results are to be communicated to the individual and drug card sponsor involved. The Secretary may enter into contracts to perform the reconsideration function.