The application process starts when an individual or someone acting for him or her files a signed application or submits a COMPASS application.
Exception: See Chapter 317 for BCCPT application procedures. Public Law 106-354
When the CAO receives the application, it must take the following steps:
Stamp the date of receipt on the application form. That is the application date, unless the application form is submitted by a provider or by a site chosen by DPW or online through COMPASS. When the application is submitted by a provider or site designated by the DPW, the application date is the date of the earliest signature on the form.
When the application is submitted through COMPASS, the application date is the date the application is submitted (which is automatically printed on the form), unless the COMPASS application is submitted by a provider. When a provider application is submitted through COMPASS, the application date is the date of first admission or treatment, as shown on the form.
Enter information from the application into the application-processing system.
NOTE: For Presumptive Eligibility Healthy Beginnings, approve category PS with program status code 17 by the third work day after getting the Presumptive Eligibility Form (MA 332) and the application form. Presumptive eligibility is approved for 45 days. 55 Pa. Code § 140.142
Help the individual in filling out the application and obtaining information to show that the application is true and honest. (See Chapter 378, Verification.)
Complete an interview, if necessary.
NOTE: A face-to-face interview is not required for any MA application. If the application and the proof that comes with it is not enough to determine eligibility, and if missing information is not available by written or phone contact, then the CAO may schedule an interview. The CAO must send an Appointment Notice (PA 253) that lets the applicant know of the interview date and the information that is needed. The appointment notice must let the person know that even if he or she has signed power of attorney, he or she needs to provide information and proof.
Approve or reject the application, and send a notice to the applicant explaining why the decision was made. If it is a provider application, copy of the notice must be sent to the medical provider 55 Pa. Code § 125.1(k)
NOTE: Applications or renewals for children whose cases were rejected or closed may qualify for CHIP. The CAO must forward them to the Pennsylvania Insurance Department for review.
A medical provider, registered as an MA provider, may complete an application, to include COMPASS, for someone who wants to receive MA. The provider must send the completed MA Application and Eligibility Determination Form (MA 314) for an inpatient application to the CAO in the county where the client lives. For GA-related MA applications, the provider must also send in a Criminal History Inquiry (PA 1666). The CAO must use the earliest signature on the application form as the application date. 55 Pa. Code § 125.84(a)
NOTE: If a provider submits a Medicaid Coverage for Pregnant Women form (PA 600PW) and the woman is not a resident of the counties that use these forms, the CAO must take the following actions:
Send the applicant a PA 600CH. The applicant or representative must fill it out. If the person is eligible, the effective date is the date stamped on the PA 600PW.
Attach the PA 600PW to the PA 600CH.
Explain the actions taken in the case record.
Exception: The date of application for a provider application submitted on COMPASS is the date of first admission or treatment, as shown on the form. The caseworker can see this information on the “Enrolled Medicaid Provider” screen.
NOTE: For information and instructions regarding an MA application that is submitted by a power of attorney, see Section 304.11.
NOTE: The CAO does not need to send a copy of the MA 314 to the hospital if a copy of the notice regarding the status of the application for MA was sent to the hospital.
If the provider has submitted all the necessary information and eligibility requirements are met, the CAO will process the application for MA eligibility.
NOTE: The CAO should expect to receive applications, including COMPASS, completed by providers. These applications may include, but are not limited to, the following:
Presumptive-eligibility applications (see Section 318.15)
Inpatient applications
Outpatient applications
Breast and Cervical Cancer Prevention and Treatment Program applications (see Section 317.1) Public Law 106-354
Applications on behalf of any individual requesting MA whether or not a service is needed or provided
NOTE: Although OIM policy regulations do not say that a signed application has to be sent in within a certain amount of time, CAOs must let providers know that they must submit applications within 60 days of when the service was provided. That way, the applicant won’t have to deal with a delay in the eligibility decision. Applications must not be rejected for eligibility purposes if they are not turned in within 60 days of a medical service.
NOTE: An individual can choose to apply only for services that already were given, for current and future services, or for a combination of those.
NOTE: Whatever the individual decides to apply for, income eligibility for MNO-MA benefits must be based on a period of six months in a row. 62 P.S. 442.1(c)
Providers listed in Appendix A or Appendix B or any site designated by the DPW can help applicants fill out the application form, including COMPASS, and other forms that are needed to determine eligibility. Any completed application must be forwarded to the local CAO along with supporting documentation.
NOTE: The individual can choose to apply only for services that already were given, for current and future services, or for a mix of past, current, and future services.
Reminder: Whatever the individual decides to apply for, income eligibility for MNO-MA benefits must be based on a period of six months in a row.
62 P.S. 442.1(c)
When processing an outstationed application, the CAO must take the following actions:
Stamp the date on the application form.
Enter the application in the application-processing system.
Review the application form to determine whether it is complete and whether other papers that are needed are attached.
If the application is complete, determine whether the applicant is eligible or ineligible and approve or reject the application. If an individual is eligible, set the date that he or she will have to have eligibility determined again. If an application and attached papers do not provide enough information, and if the CAO cannot obtain that information by written or phone contact, the caseworker must schedule a face-to-face interview.
Enter all information needed for the approval or rejection.
NOTE: The name of the child’s doctor is needed on the CABUDG screen in CIS for referral to the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program contractor.
Prepare a notice to let the applicant or the individual representing the applicant know of the eligibility decision. Send one copy to the applicant or the individual representing the applicant and another copy to the medical provider.
NOTE: Benefits must not be delayed or denied because of an incomplete EPSDT form or a missing adult signature proving that the applicant is a U.S. citizen. The CAO must contact the individual in a timely way to obtain the missing information or signature.
If the applicant does not have a Social Security number, refer him or her to the local Social Security Office, as required. (See the Supplemental Handbook,Chapter 950, Enumeration.)
Complete and send an Authorization for Release of Information (PA-4) to the client only if more information is needed to determine eligibility.
If the CAO receives an application that includes the applicant’s name, address, and signature, but the application does not have enough information or the needed proof to determine eligibility, the CAO must take the following actions:
Review the application to find out what other information is needed to determine eligibility.
If the needed information can be provided by phone or mail, make a plan with the individual to submit the information. If not, schedule a face-to-face interview.
If an interview is necessary, conduct the interview with the applicant or the individual representing the applicant and make sure all the required information is given and is true.
NOTE: If an individual does not show up for the scheduled interview and does not provide all the information needed, the CAO must deny MA benefits. However, if the individual asks to have the application interview rescheduled, the CAO must do so.
Enter the information needed for the approval or rejection.
Determine whether the individual is either eligible or ineligible and approve or reject the application.
Prepare a notice to the applicant or the individual representing the applicant know of the eligibility decision. Send one copy to the applicant or the individual representing the applicant and another copy to the medical provider.
See Chapter 317 for HWP BCCPT applications. Public Law 106-354
Updated February 14, 2012, Replacing June 27, 2008