Current through Register Vol. 51, No. 19, September 20, 2024
A. All of the
requirements of Regulation .04 of this chapter shall apply with the exceptions
stated in this chapter.
B.
Application Filing and Signature Requirements.
(1) An individual who wishes to apply for
Medical Assistance shall submit a signed application to the Department or its
designee in the jurisdiction where his residence is located.
(2) A deemed newborn is eligible for
receiving Medical Assistance if at the time of birth the child's mother was
covered in another state as a child under CHIP or under a 1115
waiver.
(3) An individual who has
filed an application may voluntarily withdraw that application; but the
withdrawal may not affect the requirements for the penalty period associated
with the transfer of a resource specified under Regulation .08I of this
chapter.
C. Period Under
Consideration. Current eligibility shall have a period of consideration of a
6-month period beginning with the month of application for Medical Assistance,
except as specified in Regulation .04H(3) of this chapter.
D. Processing Applications. When a written or
electronic application is filed, a decision shall be made promptly but not
later than:
(1) 45 days from the date of
application in the case of determination of aged and blind individuals;
or
(2) 60 days from the date of
application in the case of determination of disability.
E. Extension of Time Standards.
(1) The time standards specified in
Regulation .04I(1) of this chapter shall be extended to allow the applicant
sufficient time to complete provision of information when the examining
physician delays or fails to take a required action.
(2) Reactivation of an Application Following
a Decision of Ineligibility for Reasons Other than Nonfinancial Factors, Excess
Resources, or Excess Income.
(a) A request
for current eligibility following the rejection of an application for reasons
other than nonfinancial factors, excess resources, or excess income shall be
considered a reactivation of the appropriate earlier application.
(b) The reactivation period shall:
(i) Apply to the earliest rejected application for
which the period under consideration has not expired; and
(ii) Include the retroactive period
associated with the current period.
(c) The applicant may establish eligibility
for the current period, the retroactive period, or both, at any time during the
reactivation period.
(3)
Disposition of Application Following a Decision of Ineligibility. If an
applicant is determined ineligible for the current period under consideration
due to a nonfinancial factor or excess resources, the application shall be
disposed of and the application date may not be retained. If the applicant
reapplies, the process and the period under consideration shall be established
under Regulation .04I(9) of this chapter.
F. Interview.
(1) A face-to-face interview may be conducted at the request of
the applicant or the Department or its designee.
(2) If it is determined that a face-to-face
interview is necessary, the interview may be conducted with an individual other
than the applicant in the following situations:
(a) When the Department or its designee determines
that the applicant cannot participate in the interview because of unusual
circumstances such as severely incapacitating disabilities, the interview shall
be conducted with an authorized representative or individual acting responsibly
on behalf of the applicant; or
(b)
When the applicant is an unmarried child younger than 18 years old and is not
living with a parent or other caretaker relative, the interview shall be
conducted with one or more of the following individuals who is 18 years old or
older:
(i) The parent or other knowledgeable
relative of the child;
(ii) The
nonrelated individual with whom the child is living; or
(iii) Another designated responsible
individual who is knowledgeable about the child's
circumstances.
G.
Required Application for Income Benefits.
(1) Eligibility may not be established until
applicants, and recipients furnish proof that they have applied for and taken
all other necessary steps to obtain and accept all income benefits to which
there may be entitlement, except as specified in §N(3) of this
regulation.
(2) Income benefits
include, but are not limited to:
(a) Social
Security;
(b) Unemployment
Compensation;
(c) Railroad
Retirement;
(d) Veterans'
Administration;
(e) Civil Service
annuities;
(f) Federal, state, or
local government and private pensions; and
(g) Workers' Compensation.
(3) Applicants and recipients determined by the
Department or its designee to be unable to perform the required activity
because of the applicant's or recipient's physical or mental condition and for
whom there is no other individuals to perform the activity are not required to
apply for income benefits.
(4)
Determination of initial eligibility may not be delayed pending the results of
the application filed for income benefits.
(5) At the time of redetermination or
reapplication, eligibility will be determined on the basis of the applicant's
or recipient's documented reasonable and continuous efforts to establish
entitlement to income benefits.
H. An applicant who is 65 years old or older,
or blind or disabled, is not eligible until the applicant furnishes proof that
the applicant has applied for or is receiving Part A Medicare. Eligibility
determination may not be delayed pending the results of the application filed
for Part A Medicare. Periodic reviews of eligibility are necessary for those
blind or disabled individuals initially determined ineligible for Medicare
because of the required waiting period.
I.
Social Security Number.
(1)
Eligibility may not be established until the applicant or recipient furnishes
or applies for a Social Security number for each member of an assistance unit
and any individual whose income and resources are considered in determining the
financial eligibility of an assistance unit.
(2) An individual may not be added to an
assistance unit until an application is completed for a Social Security
number.
J. Retroactive
Eligibility for Cash Assistance Applicants or Recipients. A Public Assistance
applicant or recipient who desires Medical Assistance coverage for a past
period shall apply for retroactive coverage. The date of application for
retroactive coverage shall be established as follows:
(1) The Medical Assistance application date shall be the:
(a) Same as that of the Public Assistance
application date if the Medical Assistance application is filed within 3 months
of the date of the Public Assistance application; or
(b) Date the Medical Assistance application is filed
if the filing date is more than 3 months after the date of the Public
Assistance application.
(2) Retroactive eligibility shall be
determined in accordance with the requirements of Regulation .10C of this
chapter.
K. The
Department or its designee shall conduct a wage-screening inquiry to determine
wages, benefits, and claimant history for an Aged Blind Disabled applicants or
recipients that:
(a) Resides in a long term
care facility; or
(b) Is
chronically ill and non-ambulatory.
L. An applicant shall sign consent forms as
needed authorizing the Department or its designee to verify from sources such
as an employer, banks, and public or private agencies, information needed to
establish eligibility.
M.
Obtaining Financial Records from Fiduciary Institutions Doing Business in the
State as of October 1, 2017.
(1) The
Department or its designee shall inform the applicant or authorized
representative in a written or electronic document of the required information
and verifications needed to determine financial eligibility for Medical
Assistance and the time limit for submitting the required records.
(2) The applicant or authorized
representative shall provide all of the required information and verifications
needed to determine financial eligibility for Medical Assistance within the
time period specified in the notice from the Department or its
designee.
(3) The Department or its
designee shall request financial records necessary to determine the applicant's
eligibility for Medical Assistance on behalf of the applicant when:
(a) The applicant or authorized
representative is actively attempting to obtain financial documentation to
establish eligibility but has been unable to provide the required financial
information through no fault of his own from a certain fiduciary institution
conducting business in the State;
(b) The applicant or authorized
representative provides documentation to show their efforts to obtain the
information; and
(c) The applicant
or authorized representative provides a signed consent form designated by the
Department or its designee to obtain the records.
(4) If the conditions set forth in §M(3)
of this regulation are not met, the applicant or authorized representative
remains responsible to provide the information.
(5) Reimbursement Schedule. The Department or
its designee shall reimburse a fiduciary institution for providing copies of
financial records in accordance with the Banks and Banking regulations found in
12 CFR § 219.3, including the Reimbursement Schedule
at Appendix A.
