Application and Decision 510-03-25

 

Application and Review 510-03-25-05

(Revised 6/1/2015 ML #3441)

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IM 5275

IM 5264

 

 

(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 on a prescribed form designed and approved by the North Dakota Department of Human Services.

For ACA Medicaid Households, individuals can apply using one of the following prescribed applications:

  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, "Application for Health Coverage and Help Paying Costs";
  4. Telephonic applications utilizing any one of the prescribed applications;
  5. SFN 405, "Application for Assistance"; or
  6. SFN 641, "Title IV-E/Title XIX Application-Foster Care";
  7. The Department’s online "Application for Assistance", located at http://www.nd.gov/dhs/.
  8. Applications provided by disproportionate share hospitals or federally qualified health centers are SFN 405 with "HOSPITAL" stamped on the front page; or
  9. ICAMA (Interstate Compact on Adoption and Medical Assistance) form 6.01 "Notice of Medicaid Eligibility/Case Activation" stating North Dakota is responsible for the Medicaid coverage of the specified child.
  10. SFN 958, "Health Care Application for the Elderly and Disabled". However, notification must be sent to the individual requesting information needed to make the ACA 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. An application is considered signed if the signature is found anywhere on the application, other than to answer a question. 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.

  1. 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.
  2. 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.
  3. 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.
  1. 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;
  6. The on-line application or review through OASYS located at http://www.nd.gov/dhs/; or
  7. The streamlined application or review received through the ND Client portal for ACA Medicaid reviews.
  8. When completing a review for children eligible for subsidized adoption assistance, receipt of one of the above reviews forms is not required. However, the following two criteria must be verified:
    • The child remains a resident of North Dakota; and
    • The child continues to be eligible for the subsidized adoption program.

    In addition contact should be made with the household to determine whether the child has obtained or lost other insurance coverage.

  1. When a review is due for an ACA individual, the individual does not provide the review form or requested information and loses eligibility 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.

When the review form is received on the 90th day but is incomplete or does not include all of the requested verifications, the review must be denied and the individual informed that they must reapply.

When the review form is received but does not include verification for one or more of the months during the 90 day period:

  • If the verification is not received for any month other than the month the review is received or the month prior to the month the review was received, the review must be completed and eligibility determined for the months the information was received. The months in which the verifications were not received must be determined not eligible. Should the individual provide the verifications during the 12 month period after the month that was determined ineligible, eligibility can be determined.

     

  • If the verification is not received for the month the review was received or the month prior to the month the review was received, but was for any month between the case closure and review receipt date, eligibility can be determined for the months the information was received. However, the case must be closed at the end of the month for which the verifications were received.

Note: If any children were determined ‘CE’ eligible, they will remain eligible. However, the caretaker’s eligibility would end.

 

  1. 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 an 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.
  1. 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.
  1. 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 basis.)
  1. 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.
  1. Reviews must be completed and processed no later than the last working day of the month in which they are due.