b. Applicable Individual or Dependent Must Travel Outside of Their Community for an Extended Period of Time To Receive Medical Services Necessary for a Serious or Complex Medical Condition

As specified at § 435.555(d)(4), an applicable individual experiences a short-term hardship if the applicable individual or their dependent must travel outside of their community of residence for an extended period of time to receive medical services necessary to treat a serious or complex medical condition, as defined at § 435.554(c)(5)(i)(E), that are not available within their community of residence. States must first attempt to verify the serious or complex condition and receipt of medical services, including the location where and the date(s) on which the services were received, using reliable information available to the State, including adjudicated claims or encounter data as relevant to the individual for the preceding 12 months and information from other electronic data sources (as applicable) However, we anticipate there will be instances in which no reliable information is available to the State, particularly when the applicable individual's dependent, and not the applicable individual, needed to travel outside of their community of residence ( printed page 33410) to receive care. Beginning on January 1, 2028, when no reliable information is available to the State, the State must require documentation if documentation is reasonably available, such as medical records providing the dates and location of services. The State must also establish procedures to accept other information in the absence or reasonably available documentation.

In addition, the State must verify the relationship to the individual who received care, if that individual was the applicable individual's dependent. To the extent possible, the State must use information available in the applicable individual's case record or the State's eligibility system, such as household composition data collected at application, to verify the relationship. If the information is not available in the case record or eligibility system or using other reliable information available to the State, the State must seek additional information to verify the relationship. Beginning January 1, 2028, the State must obtain documentation if such is reasonably available. If documentation is not reasonably available, the State must have procedures in place to accept other information sufficient to verify the individual's eligibility (as determined by the State). We note that the latitude described in section II.I.3. of this IFC allowing States to accept other information even if documentation is reasonably available through January 31, 2027, does not apply to verifying guardianship status. If the applicable individual is the dependent's legal guardian, a court order or other legal instrument is required to verify the relationship.

While an applicable individual is not required to travel with their dependent for necessary medical treatment, for such an applicable individual to receive this short-term hardship exception, the State must verify that the applicable individual had to take leave from employment or had to absent themselves from other community engagement activities for reasons related to the dependent's condition or travel. Section II.G.7. of this IFC provides examples of reasons related to the dependent's condition or travel.