Any individual who wants to apply for Medical Assistance (MA) benefits can ask for an application by contacting the County Assistance Office (CAO). Applicants can also apply online using the Commonwealth of Pennsylvania ACCESS to Social Services system (COMPASS, http://www.compass.state.pa.us).
NOTE: The CAO must never tell an individual that he or she is ineligible and cannot apply.
The applicant may be the individual, a medical provider, a representative of a hospital or institution, a child welfare agency for a foster child, or any individual applying for someone who would like to receive MA. 55 Pa. Code § 123.72 55 Pa. Code § 123.82
An individual may have signed a power of attorney to allow a medical provider or someone else to apply for him or her. When power of attorney is granted, the individual is still responsible for the information provided on the application.
A power of attorney (which must be dated and signed) gives only the powers that are listed in it. It gives those powers only to the individual who is specifically named in the power of attorney. A power of attorney cannot be transferred or assigned to a third party unless the individual who gave it agrees to that.
Example: John Smith gives power of attorney to Jane Doe. Jane Doe tries to give this power of attorney to Les Jones. The power of attorney cannot be used by Les Jones unless the power of attorney signed by John Smith named Les Jones as an alternate.
When a power of attorney is submitted with an application for benefits, the CAO must go ahead with the application process with only the individual or agency representative specifically named by the individual in the power of attorney. The CAO must not go ahead with the application process with a third party not specifically given power of attorney by the individual. If more information is needed to determine eligibility, the CAO must contact the individual who gave power of attorney.
Sometimes, signed powers of attorney are included with MA applications from hospitals. A power of attorney given by an applicant to a representative of a hospital also cannot be transferred to a third party unless the applicant allows it.
If an individual from a collection agency appears at the CAO to represent an individual regarding an application filed at a hospital, the CAO must find out and note whether the collection agency has been hired by or represents the hospital. A collection agency is not allowed to act for an individual who is applying for MA when it has been hired by or represents a hospital or other provider of services to that individual.
A collection agency can provide third-party proof (for example, proof of wages or Social Security benefits), which the CAO can accept to help in determining an applicant’s eligibility. If more information is needed to determine eligibility, the CAO must contact the applicant. 18 Pa. C.S. Section 7311(d)
An applicant must fill out the COMPASS or PA 600 series application and submit it or turn it in to the CAO. If he or she needs help completing the form, the CAO must help. The CAO must accept the application if it contains the individual’s name, address, and signature.
NOTE: A PA 600 FSO may be used. The CAO may need to call the individual for information that is not on the application.
NOTE: The CAO must accept an application from a homeless individual even if no address is given.
A COMPASS application submitted online (over the Internet) may not have a signed signature page. It must be accepted without a signature, and the applicant must provide a signed signature page within 30 days from the date of application. If an individual needs help filling out a COMPASS application, the CAO must tell the individual to call the Department of Public Welfare (DPW) helpline for help.
Also, a COMPASS application that is electronically signed and submitted by an individual or a community partner is considered a signed application. A community partner is a registered organization or agency that assists individuals with applications for benefits.
NOTE: An applicant can fax applications, signature pages, and required documentation for COMPASS and the PA 600 series applications to the CAO.
An individual may also apply for MA at a hospital, a federally qualified health center, or any site chosen by the DPW.
NOTE: A woman can apply for the Breast and Cervical Cancer Prevention and Treatment (BCCPT) Program only through a HealthyWoman Project (HWP) contractor. (See Chapter 317, BCCPT, Appendix B.)
The PA 600 series or COMPASS application can be used for any type of medical program. No one needs to apply for a specific program or to apply for different programs in a certain order. The CAO and each applicant must decide which program is best for the applicant.
Exception: The PA 600 CH may be used only by families with children, by pregnant women or by families of children in the special-needs category who apply for health care benefits under the MA program or the Children’s Health Insurance Program (CHIP).
NOTE: The CAO can accept the Social Security Administration's (SSA) Medicare Savings Plan (MSP) model application for the MSP program, also known as Buy-In. The CAO may need to contact the individual for additional information not provided on the MSP model application.
The CAO must use the application date when deciding whether someone is eligible for MA. The date of application is one of the following:
The date when the CAO gets and stamps a signed application form
The earliest date the application is signed by the applicant if it is submitted by an MA provider or at any site chosen by the DPW
The date when a COMPASS application is submitted online
The date of first treatment or admission if the COMPASS application is submitted by an MA provider
Exceptions:
For a GA-related NMP (PD) applicant who establishes eligibility, ongoing MA benefits must be allowed as of the date all conditions of eligibility are verified.
An applicant for Medical Assistance for Workers with Disabilities (MAWD) who needs to have a Medical Review Team (MRT) review can ask for eligibility to begin on (a) the first day of the month in which the application is turned in or (b) the first day of the following month.
NOTE: If the MAWD applicant decides to begin coverage in the month in which the CAO receives the application, the applicant must pay the premium payments for that month.
If an application is held longer than 30 days, the CAO must contact the applicant by letter and follow up with a telephone call to let him or her know of a possible change in the begin date for eligibility.
See Chapter 317 for the begin date for eligibility under BCCPT.
An application may be made before someone receives medical services or even if he or she does not expect to need medical services.
An individual can apply for benefits for past medical services if he or she has an unpaid medical expense from before the application date. Benefits for past medical services may be approved for the period starting with the first day of the third month before the date of application. The individual may choose to apply for either (a) retroactive-only, (b) continuing-only, or (c) combined retroactive and continuing MA benefits. 55 Pa. Code § 141.71(f) 55 Pa. Code § 141.81(g)
Exception: There is no retroactive coverage under Presumptive Eligibility or Healthy Horizons Cost-Sharing programs. Retroactive MA coverage may be allowed under the Healthy Horizons, Children with Special Needs, and Healthy Beginnings Programs.
NOTE: Income eligibility for MNO benefits must be based on a period of six months in a row. 62 P.S. 442.1(c)
The CAO must let every applicant know that the online application is available on the Internet (at http://www.compass.state.pa.us) and offer to give or mail the PA 600 series application form to the applicant. The application forms should also be available at medical provider sites and any other sites designated by the DPW. Only one application form is needed for all individuals applying in a group. All individuals living together when the applicant signs the application form must be listed on the form. Eligibility for several programs may be approved or rejected based on a single application form. 55 Pa. Code § 123.72 55 Pa. Code § 123.82
An application form is not needed for any of the following:
Reapplying within 60 days from the date of application.
Reapplying for MA within 60 days of a termination (closure) of eligibility for MA
NOTE: A new application is required if the people reapplying for MA include anyone new who wants to apply for MA and if application denial or MA closure was due to reasons related to income and/or resources.
Adding a child who is coming back into the household from substitute care or from another household
Adding a newborn
Opening extended medical coverage (EMC)
Renewing or redetermining eligibility even if the category changes
NOTE: The CAO must conduct a case review as often as needed, depending on the circumstances of the applicant/recipient group (see Section 370.5). The CAO must use the date when the applicant asked for more MA benefits as the effective date of the new category if all eligibility criteria are met. If a decrease in income makes an individual eligible for NMP, the CAO must change the MA budget from MNO to NMP based on the client’s statement.
Closing a cash or SSI budget and opening any MA budget
Changing from one MA budget or category to another
NOTE: If a TANF or TANF-related (PC-03, PC/PU-15, or PC/PU-27) budget is closed because of an increase in support payments, the caseworker must review each member for potential MA eligibility. See Section 338.43, TANF Stopped Because of Payment of Support.
NOTE: Before opening an EMC budget, the caseworker must review the budget and determine whether it is eligible for MA in one of the TANF-related NMP categories (PC-03, PC/PU-15, or PC/PU 27). The caseworker must make a note of this review in the case record. See Chapter 339, Extended Medical Coverage.
Changing categories within MNO
NOTE: A new application is needed for allowing NMP spend-down if an individual has not received NMP spend-down for three months in a row.
An inquiry is different from an application. With an inquiry, an individual wants to receive information, but he or she does not want to file an application for benefits at this time. When someone asks for benefits or other services on behalf of a competent adult, the CAO must consider the request an inquiry. The application process can begin when the CAO knows that the competent adult knows about the request and agrees to have it made.
MA applications completed at sites other than the CAO in the county where the applicant lives must be forwarded to that CAO. An application started by a client at a CAO must be made in the county where the applicant lives. 55 Pa. Code § 125.84(b)
Applications may be submitted online using COMPASS. COMPASS applications are sent to the correct CAO based on the applicant selecting the county where they live. COMPASS is available anytime.
Applications for BCCPT must be completed at the HWP contractor site. Public Law 106-354
NOTE: A homeless individual does not need an address.
A resident who is temporarily living in another county or state (for reasons such as receiving inpatient hospital care or going to school) may complete the application and forward it to the CAO in the county of residence. The CAO in the county of residence must process the application and determine eligibility.
NOTE: If the application is turned in to the county where the individual is temporarily living, the CAO must forward the application to the CAO in the county of residence. (See Chapter 323, Residence.)
The applicant or someone who represents the applicant, regardless of age, must sign the application form before turning it in to the CAO or a place chosen by the DPW. 55 Pa. Code § 125.1(d)
COMPASS applications that are submitted online may not have a signed signature page. The individual must provide a signed signature page within 30 days from the date of application. If the signed signature page is not received within 10 days after the COMPASS application is submitted, the IMCW must send a follow-up letter with a copy of the signature page and DPW letter (Letter 2—see Chapter 304, Appendix D).
A COMPASS application that an individual or community partner e-signs and submits electronically is the same as a signed paper application.
NOTE: The receipt of faxed or scanned applications, signature pages, and required documentation is acceptable for COMPASS and the PA 600 series applications.
A face-to-face interview is not needed for any application for MA. However, if there is not enough information to determine eligibility in the application and proof, and if the caseworker cannot obtain the information by written or phone contact, then a face-to-face interview may be needed. If there is an interview, the applicant must sign the application again.
If the application form is first signed by an unemancipated minor, the CAO must obtain the signature of a parent or other adult who can take action for the child.
NOTE: If a provider or someone at a place chosen by the DPW submits the application, then the CAO must determine eligibility based on the date the application form was signed by the unemancipated minor. A determination of eligibility for COMPASS applications is based on the date the application was submitted to the CAO. The submit date, which is systematically printed on the COMPASS application, is the start date for the 30-day medical application processing time.
The MA payment name is applicant named on the application as head of household or anyone the applicant chooses.
When someone asks to add an individual to the applicant or recipient group, other than a newborn or someone returning within 60 days, that is considered an application. An application form is needed for the new individual. For the other individuals in the group, it is considered a renewal of benefits.
55 Pa. Code § 123.72 55 Pa. Code § 123.82
Exceptions:
Any renewal form or the COMPASS renewal e-form can be used to add household members or to approve benefits to new MA budgets in the categories of TANF-related MA (PC/PU/TC/TU), Healthy Beginnings (PS-16), and GA-related categories for families that include children under age 21 (PD/TD), as long as the CAO has enough information to determine MA eligibility. An application will still be needed to add individuals living in households without children, especially GA households.
A newborn child is automatically eligible as of the day he or she is born if the child's mother is eligible for cash assistance, MA or CHIP at the time of the newborn's birth.
An application is not needed to add a child reentering a household from substitute care or another household.
If someone has died, a relative, friend, or representative from an institution or agency that provided services to that individual may complete an application for that individual. The CAO must accept an application for this individual if he or she died within three months of application (specifically, after the first day of the third month before the month of application). Eligibility requirements, including determining who is included in the applicant/recipient group, are the same as for any living individual. 55 Pa. Code § 123.72 55 Pa. Code § 123.82
Updated April 25, 2012, Replacing February 14, 2012