The CAO must conduct a face-to-face interview only if one is needed. The individual interviewed may be the individual or any other individual applying for him or her. The individual may bring anyone they wish to the interview. 55 Pa Code § 125.84 (c)
When necessary, the CAO will schedule an appointment interview for the individual and send an appointment notice (PA 253) letting him or her know of the interview date if:
The application and the proof that the information is true is still not enough to make an eligibility determination and
The information that is still needed cannot be obtained by written or telephone contact.
NOTE: The CAO must inform the individual of what information is needed to complete the eligibility determination. The appointment notice must inform the individual that signing a power of attorney does not let him or her give up the responsibility to provide information and be able to show that it is true.
When an interview is needed, the CAO will interview a responsible member or representative of the individual group to help determine eligibility.
The CAO may make a home visit only in situations when it believes that there is a good reason for one.
NOTE: Before making a home visit, the caseworker must get the approval of a supervisor.
For applications started at or completed in the CAO, the CAO must take the following actions. An application may not require all the actions, depending on the circumstances of the individual. 55 Pa Code § 125.84 (d)
Review the information on the application.
Reminder: If the individual answers yes to the question of whether SSI stopped because of an increase in Social Security benefits or whether he or she received Social Security benefits, then the CAO must review the application for possible MA coverage under Extended NMP—Special Circumstances. (See Chapter 387, SSI). An individual may be eligible as a disabled adult child (DAC) or under the “Pickle amendment” disregard of COLAs.
Allow the individual to present his or her situation and explain the need for MA.
Look over the application and fill in any information that is incomplete. Inform the individual of what other information is needed to establish category or eligibility.
Important: If no income or limited income is reported on the application, the CAO will request more information to explain how the household lives on little or no income.
Complete or update the information on the application based on the facts that the individual gives during the interview. Look over the information already in the case record and resolve anything that does not look right.
Ensure that each member of the applicantl/recipient group has a Social Security number (SSN). Refer each individual who does not have an SSN to the local Social Security Office, as required. (See the Supplemental Handbook, Chapter 950, Enumeration.) 55 Pa. Code § 155.2
Determine whether there are medical expenses that have not been paid that were for medical services provided before the application was submitted. These may include expenses paid by a third party. Ask the individual if he or she wishes to apply for either (a) retroactive-only (if the services took place before the date of the application), (b) continuing-only, or (c) combined retroactive and continuing benefits. 55 Pa. Code § 141.71 (f) 141.81 (g)
Reminder: Regardless of how the individual answers that question, income eligibility for MNO benefits must be based on a period of six calendar months in a row. 62 P.S. 442.1(c)
Reminder: Past medical services are not covered under presumptive eligibility or Healthy Horizons Cost-Sharing programs, however, an individual can apply and be open retroactive by the Medicare Savings Program (MSP), also known as Buy-In. Retroactive MA coverage can be approved under the Healthy Beginnings Program for a mother who makes application for MA after her child is born but still within the month of the birth of the child. The child would also be eligible for Healthy Beginnings back to the date of birth. (See Section 318.9, Approving Healthy Beginnings.)
If applicable, have the individual fill out the Criminal History Inquiry Form. (See Appendix C for procedures.) 62 P.S. 481.1
If applicable, explain and fill out an Agreement and Authorization to Pay a Medical Assistance Claim (PW 176-KM). Give the individual a copy of the signed form. 55 Pa. Code § 257.24 (2)(i)(A)
Example: Reimbursement for MA expenses is required if there is a settlement of a lawsuit from a car accident, personal damage award, or other personal injury claim. 55 Pa. Code § 178.6 62 P.S. 1409
Explain basic program requirements and procedures, including copayments and GA-related deductible requirements. (See Chapter 338, Appendix D and Section 338.521.)
Inform the individual that he or she must report any changes in circumstances as follows: 55 Pa Code § 125.24 (d)
Changes unrelated to income, such as if someone is added or deleted from the budget group or if his or her resources change, must be reported by the tenth day of the month after the change takes place.
An increase of more than $100 in gross monthly earned income must be reported by the 10th day of the following month.
An increase of more than $50 in gross monthly unearned income must be reported by the 10th day of the following month.
Important: Be sure to give the individual the rights and responsibilities page from the application and review it with the individual to be sure he or she understands it.
Inform the individual of his or her right to appeal the CAO’s decision regarding eligibility if he or she does not agree with the decision.
Explain the use of the Authorization for Release of Information (PA 4) form when contact is needed with a third party to obtain or confirm information. Fill out the form only if the individual or representative cannot obtain needed information to show that he or she is eligible. If the PA 4 is necessary, people applying for or receiving benefits who are 21 years of age or older or under age 21 and emancipated must sign the PA 4 within 30 days from the date of approval of benefits. 55 Pa. Code § 201.4(2)(ii) 55 Pa. Code § 125.1(e)
NOTE: When a face-to-face interview is not needed and a PA 4 is needed, the PA 4 must be mailed to the individual for his or her signature.
NOTE: If an individual who needs to sign the form does not do it, that individual becomes ineligible for benefits or continued eligibility.
Advise the individual to read the affidavit on the application form, or read it to the individual. Have the individual or representative sign the affidavit.
Inform the individual that he or she must cooperate with quality control (QC) reviews. (See Section 304.44.) 55 Pa. Code § 111.4(b)(5)
Make sure the identity of the individual is correct, and note on the application how the identity was proven (driver’s license, selective service card, voter registration card, or other form of proof). 55 Pa. Code § 125.1(b)
Offer the individual a voter registration form. If he or she would like to register, help the individual complete the form if he or she needs help. (See (Supplemental Handbook, Chapter 980, Voter Registration.)
Report anything that looks like possible child abuse to the Executive Director or designee.
Explain the benefits of the EPSDT program. Provide the EPSDT brochure for every recipient under age 21, and enter the name of the child’s doctor on the CABUDG screen so that he or she can be referred to the EPSDT contractor.
If the individual is reapplying for MAWD and there are unpaid premiums , let the individual know that he or she must pay unpaid premiums before MAWD benefits can be approved.
The individual providing most of the information is the applicant The applicant's responsibilities are as follows: 55 Pa. Code § 201.1(1)
Cooperate in obtaining the proof needed to show that he or she is eligible.
Give true and complete information on anything that relates to or affects his or her eligibility.
Say whether he or she is applying for retroactive-only, continuing-only, or combined retroactive and continuing benefits.
Participate in an interview if it is necessary to obtain the information needed to determine eligibility. 55 Pa Code § 125.84 (c)
Give information about any medical coverage that is being paid for by another individual or organization. 55 Pa. Code § 125.24 (b)(1)(vi)
Show proof of citizenship and identity, or get help in obtaining proof. See Section 322.2, Citizenship and Section 320.2, Proof of Identity.
Sign an Authorization for Release of Information (PA 4), if required, agreeing to have information from third parties released. 55 Pa. Code § 201.4(2)(ii)
NOTE: An individual applying for MA who is 21 years of age or older or under age 21 and emancipated must also sign the PA 4, if one is required.
NOTE: For applications taken without a face-to-face interview, if needed the CAO must mail the PA 4 to the individual for signature.
Cooperate in helping to determine if anyone in the applicant/recipient group is eligible for possible resources or sources of income.
NOTE: If anyone who has an affect on decisions related to MA benefits is eligible for other benefits, that individual must apply for those benefits, regardless of whether or not he or she is applying for MA. If the individual does not cooperate and does not have a good reason for not cooperating, he or she becomes ineligible for TANF-related MA and SSI-related MA until he or she cooperates. If he or she is a GA-related individual, the individual becomes ineligible for MA for at least 60 calendar days and until he or she cooperates. This rule does not apply to child support.
Example: Mary is applying for MA for her daughter, Alice (age 9), but does not wish to apply for herself. It appears that Mary might be eligible for Social Security Disability benefits. Mary is notified that she must apply for Social Security, but she refuses. Because the amount of benefits Mary could receive would affect the MA decision, Alice is not eligible for benefits until Mary complies.
NOTE: A MAWD individual does not need to apply for SSI or Title II Social Security Disability Insurance (SSDI) benefits as a condition of eligibility. (See Chapter 316, MAWD, Section 316.2, Deciding on Eligibility.)
Give DPW the right to ask to be paid by any liable third party for the amount of medical expenses paid.
Agree to let payments from Medicare be made directly to providers.Give the DPW the right to inspect, review, and copy any and all medical records for services received through the MA program.
Agree to pay the monthly amount that needs to be paid (the premium) to DPW if he or she becomes enrolled in MAWD.
The CAO must let the individual know that every recipient must cooperate with state and federal quality control (QC) reviews. If a recipient does not cooperate, he or she becomes ineligible for the program that is being reviewed. If an individual’s eligibility for MA is stopped because of noncooperation with QC, MA may not be allowed until QC approves the request for MA benefits. (See the Supplemental Handbook, Chapter 900, Quality Control.) 55 Pa. Code § 111.4(b)(5)
Updated February 14, 2012, Replacing June 27, 2008