Application and Decision 510-05-25

 

Application and Review 510-05-25-05

(Revised 10/1/13 ML #3390)

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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 in 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 and pregnant women (MAGI 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”.

 

For aged and disabled individuals; Medicare Savings Programs, Foster Care, Subsidized Adoption (Non-MAGI households):

  1. SFN 405, "Application for Economic Assistance Programs";
  2. SFN 641, "Title IV-E/Title XIX Application-Foster Care";
  3. SFN 1803, "Subsidized Adoption Agreement";
  4. SFN 958, "Health Care Application for the Elderly and Disabled";
  5. The Department’s system generated "Statement of Facts" (this may no longer be accepted as a Medicaid application after 12-31-13);
  6. The Department's online "Application for Economic Assistance Programs";
  7. The Low Income Subsidy file from SSA;
  8. If within one calendar month of when an applicant's Medicaid case was closed, or as part of the Healthy Steps annual review, one of the prescribed review forms (see subsection 2(b);
  9. Applications provided by disproportionate share hospitals or federally qualified health centers are SFN 405 with "HOSPITAL" stamped on the front page; or
  10. 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.
  1. There is no wrong door when applying for Medicaid or any of the Healthcare coverages. 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: Community spouse lives in one county, institutionalized spouse in another. If it is more convenient for the household to apply and maintain the case in the county where the community spouse resides than the county in which the institutionalized spouse is living, the community spouse’s county 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 acounty 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, none are 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. SFN 856, "Adoption Subsidy Agreement - Annual Review" for subsidized adoption, or other confirmation from  a state IV-E agency (in state or out of state) that verifies continued IV-E subsidized adoption  eligibility;
  6. One of the previously identified applications completed to apply for another program;
  7. The on-line review through OASYS; or
  8. The streamlined review received through the state portal for MAGI reviews.

When a MAGI household 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 is submitted within 90 days after the termination, eligibility must be reconsidered back to the termination date.

 

Ex Parte Reviews: For both MAGI and non-MAGI households, 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 MAGI 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: For MAGI households only, the county agency must make a review of eligibility without requiring information from the MAGI individual or MAGI 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.

 

In order to facilitate and simplify the implementation of the Affordable Care Act, a waiver has been approved to postpone reviews for households required to be processed under MAGI methodologies in the first quarter of 2014 to the corresponding month in the second quarter of 2014. Those households that are required to continue to be processed as non-MAGI will have their reviews due at the normal time. Mixed households of both MAGI and non-MAGI individuals are subject to the postponed reviews.

  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. Transitional Medicaid Benefits), 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 (other than children who are adopted through the state subsidized adoption program, which requires an application) who move from an existing case to their own case (e.g. an 18 year old caretaker moves to her own case; a disabled child turns age 18; or a child goes into foster care).
  3. A recipient may choose to have a face-to-face or telephone interview for their review; however, none are 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.