Application and Decision 510-03-25

 

Application and Review 510-03-25-05

(New 7/1/2014 ML #3404)

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(N.D.A.C. Section 75-02-02.1-02)

 

  1. Application.
  1. All individuals wishing to make application for Medicaid must have the opportunity to do so, without delay.
  2. A relative or other interested party may file an application on behalf of a deceased individual to cover medical costs incurred prior to the deceased individual's death.
  3. An application is a request for assistance:

For adults, families with children, pregnant women and Medicaid Expansion (ACA Medicaid Households):

  1. The electronic file received by the state from the Federally Facilitated Marketplace (FFM) containing the single streamlined application;
  2. The single streamlined application as submitted through the North Dakota client portal;
  3. The SFN 1909 paper “Application for Health Coverage and Help Paying Costs”;
  4. Telephonic applications;
  5. SFN 405, “Application for Assistance”; or
  6. The Department’s online “Application for Assistance”, located at http://www.nd.gov/dhs/.

ACA individuals who are applying may also apply for assistance using one of the prescribed applications used for Non-ACA Medicaid. However, notification must be sent to the individual requesting information needed to make an eligibility determination.

  1. There is no wrong door when applying for Medicaid or any of the Healthcare coverage’s. The experience needs to be as seamless and with as few barriers as possible.
  2. North Dakota Medicaid applications may be received, filed and maintained at any county office within the state, based on what is most convenient for the applicant or recipient.

Example: Mom and one child reside in one county, and another child is attending school in another. If it is more convenient for the household to apply and maintain the case in the county where the mom resides than the county in which the child, who is a student, is residing, the county where mom resides should process and maintain that case.

  1. A prescribed application form must be signed by the applicant, an authorized representative or, if the applicant is incompetent or incapacitated, someone acting responsibly for the applicant.
  2. The date of application is the date an application, signed by an appropriate person, is received at a county agency, the Medical Services Division, a disproportionate share hospital, or a federally qualified health center. The date received must be documented. Applications must be registered in the eligibility system as soon as possible upon receipt, but no later than the fifth day following receipt. Applications will be considered received on the day submitted. If an application is submitted after business hours, on a weekend or holiday, the application will be considered received on the next business day.
  3. An application is required to initially apply for Medicaid, to re-apply after a Medicaid application was denied, to re-apply after a Medicaid case has closed, or to open a new Medicaid case for a child who has been adopted through the state subsidized adoption program.
  4. A recipient may choose to have a face-to-face or telephone interview when applying for Medicaid. However, an interview is not required in order to apply for assistance.
  5. Information concerning eligibility requirements, available services, and the rights and responsibilities of applicants and recipients must be furnished to all who require it.
  1. Review.
  1. A recipient has the same responsibility to furnish information during a review as an applicant has during an application.
  2. A review must be completed at least annually using the Department's:
  1. System generated "Monthly Report";
  2. System generated "Review of Eligibility;"
  3. SFN 407, "Review for Healthcare Coverage";
  4. SFN 642, "Title IV-E/Title XIX Redetermination-Foster Care" for children in Foster Care, or other confirmation from a state IV-E agency (in state or out of state) that verifies continued IV-E foster care eligibility;
  5. One of the previously identified applications completed to apply for another program;
  6. The on-line review through OASYS located at http://www.nd.gov/dhs/; or
  7. The streamlined review received through the state portal for ACA Medicaid reviews.

ACA individuals may also complete a review using one of the prescribed review forms used for Non-ACA Medicaid. However, notification must be sent to the individual requesting information needed to make an eligibility determination.

 

When an ACA individual is requested to provide information OR a review form and loses eligibility for failure to provide a renewal form or required information, if the renewal form and all information to determine eligibility is submitted within 90 days after the termination, eligibility must be reconsidered back to the termination date.

Example: A case closed June 30 as the household did not submit their review, which was due in June. On September 5th, the household provided their Review Form and verification of income and expenses for July and August. Since the household provided the review form and all verifications within 90 days, eligibility must be determined back to the 1st day of the month following the month the case closed, July 1st.

Ex Parte Reviews: In circumstances where a desk review is appropriate, such as when adding a child, moving to Transitional Medicaid Benefits, processing a change in the level of care, aligning review dates with Healthy Steps, SNAP, or TANF, or adding Medicare Savings Programs coverage; and in which the county agency has all information needed to complete a review, eligibility may be established without a review form. When the county agency has all information needed to complete a review, continued eligibility must be established without a completed form or requiring additional information from a ACA Medicaid Household. In circumstances in which information needed to complete a review is available through Healthy Steps, SNAP or TANF, that information must be used without again requiring that information from the individual or family. If all needed information is available, a review can be completed without requiring a review form. Care must be used to ensure all needed information is on hand. An online narrative must document the completion of the Ex Parte review.

Passive Reviews: The county agency must make a review of eligibility without requiring information from the ACA individual or ACA Medicaid household if able to do so based on reliable information available in the individual’s account or other more current information available such as through any available data bases. In these cases, the individual/household must be notified of the eligibility determination and basis and that the individual/household must inform the agency if any of the information contained in the notice is inaccurate. The individual is not required to sign and return such notice if all information in the notice is accurate.

 

  1. A review must be completed within thirty days after a county agency has received information indicating a possible change in eligibility status, when eligibility is lost under a category (e.g. SSI to non-SSI), or when adding an individual to an existing Medicaid case. When the county agency has all information needed to determine eligibility based on a change in circumstances, a review form does not have to be completed. When additional information is needed one of the forms identified in b. must be used.
  2. A review, using one of the forms identified in b, is required to open a new Medicaid case for recipients who move from an existing case to their own case (e.g. an 18 year old attains age 19, moves out of the parental home, on other than a temporary purpose.)
  3. A recipient may choose to have a face-to-face or telephone interview for their review. However, an interview is not required in order to complete a review.
  4. Reviews must be completed and processed no later than the last working day of the month in which they are due.