e. Notifying Individuals About Eligibility Decisions and Changes in Eligibility Requirements

States are required to provide all applicants and beneficiaries with “timely and adequate written notice of any decision affecting their eligibility” (§ 435.917(a)), which includes eligibility approvals, denials, and terminations. In the case of eligibility terminations, such notice must be provided at least 10 days in advance of the date of action (§§ 431.201, 431.211). Further, States must provide individuals with information on their eligibility requirements and rights and responsibilities (§ 435.905). Eligibility determination notices must include a clear statement of the basis of eligibility, consistent with § 435.917(b)(1)(i), or a statement of the State's intended action and the specific reasons for the action, consistent with § 431.210(a) and (b), as applicable.

In the context of eligibility under § 435.119 or a section 1115 demonstration that includes applicable individuals as specified at § 435.556(d), the State must inform applicants and beneficiaries of the State's eligibility determination. The notice must address whether the individual meets the criteria as a specified excluded individual as defined at § 435.554. If the individual does not meet the criteria for a specified excluded individual and is an applicable individual as defined at § 435.551, the notice must also address if the individual demonstrates community engagement under § 435.552, including if the individual meets the criteria for an exception under § 435.553 or, if applicable, § 435.555, to be deemed as demonstrating community engagement, for the month(s) specified under § 435.556(a). Applicants and beneficiaries have the right to request a fair hearing to appeal the State's decision that an individual meets the criteria to be a specified excluded individual and their compliance with the community engagement requirement (including meeting the criteria for an exception), consistent with § 431.220(a)(1).

We also consider the loss of a beneficiary's status as a specified excluded individual and becoming an applicable individual to be an “action” under § 431.201. This change reduces eligibility because it adds new eligibility requirement that the individual must meet to maintain their eligibility. Therefore, the State must provide a beneficiary who is losing their specified excluded individual status with a minimum of 10 days advance notice and fair hearing rights consistent with §§ 435.917 through 435.918 and part 431 subpart E. The advance notice must include the outreach material at § 435.561(c), consistent with § 435.561(b)(3)(iv)(C).