An applicant is any individual who wishes to apply for MA benefits.
MA applications are available at the following locations:
County Assistance Offices (CAOs).
Hospitals, including general, psychiatric, and rehabilitation hospitals.
Federally qualified health centers.
Other sites that have agreed to provide application help in the community or that have outreach arrangements with the CAO.
NOTE: See Chapter 304, Application for more information about applying for MA.
Children, pregnant women, and families can use a simple MA application form called Application for Health Care Coverage (PA 600HC). Using this client-friendly form may quicken the determination process. Any pregnant woman or family with children under age 21 who wants to apply for MA should use it.
A child born to a woman who is receiving MA on the date of the child's birth automatically receives MA coverage for one year.
The newborn does not need an MA application. The hospital, the parent or another good source can let the CAO know of the baby’s birth. The CAO can then approve MA to start on the day the baby was born.
To make sure a newborn starts receiving MA as soon as possible after birth, the DHS has a liaison (contact person) for providers at each CAO. After the CAO learns of the child’s birth, the liaison makes sure that MA is approved quickly and lets the medical provider know the child’s recipient number and related billing information.
Providers will submit an MA 112 form to the CAO within three working days after the child's birth. The CAO will return the completed forms to the providers within three working days after receiving them.
If a bill is received for newborn services for a child who is not in CIS/e-CIS, the system will display a “baby alert.” The CAO will respond to the alert by approving MA for the newborn, effective on the child's date of birth.
NOTE: See Chapter 338, Medical Assistance Benefits, for additional information about newborn eligibility.
The Children’s Health Insurance Program Reauthorization Act (CHIPRA), effective April 1, 2009, included newborn eligibility provisions that the state’s MA and CHIP programs must follow. Newborn eligibility policies are as follows:
A child born to an MA or CHIP mother is automatically eligible for MA or CHIP on the date of birth and remains eligible until age one. A separate application or eligibility determination is not required for the child.
The CAO does not continue eligibility for a newborn who moves permanently to another state.
For MA, the newborn is to be covered under a categorically needy (NMP) MA category. The CAO should reference the MA category cascade for determining the correct category when adding the newborn.
The newborn is eligible for MA from the date of birth until age one regardless of whether the newborn does not come home from the hospital to live with the mother, does not remain a member of the mother’s household, or the mother is no longer eligible for MA.
NOTE: An adopted newborn, born to a birth mother on MA or CHIP is eligible for the automatic one year MA or CHIP eligibility.
If the CAO is aware that the newborn was adopted and the CAO knows the adoptive parents, the CAO is to attempt to contact the adoptive parents and offer the one year automatic MA coverage and send as eligibility to the adoptive parents.
If the adoptive parents do not want MA coverage for the newborn but the hospital remains unpaid, the CAO is to open the newborn in its own record from the date of birth to the date of discharge from the hospital and make a request to the adoptive parents to decline MA coverage. Narrate all action in the record.
NOTE: If the adoptive parents are known to the CAO and are receiving other benefits in an open case record then the newborn must be opened in the existing case record.
If the CAO is aware that the newborn was adopted, but the CAO does not know the adoptive parents, the CAO is to authorize a period of Non-continuous Eligibility (NCE) for the newborn in his or her own record. The NCE will begin on the date of birth and end on the date of discharge from the hospital. The CAO will suppress the eligibility notice. if the adoptive parents eventually contact the CAO and still want the newborn covered under MA then the CAO is to open the newborn for the automatic one year of coverage from the date of birth, narrate all actions in the record.
NOTE: If a newborn does not go home with the birth mother and the newborn’s whereabouts are known, the CAO should open the newborn in its own case record and list the guardian or caretaker as the payment name.
EXAMPLE: A pregnant woman active on MA gives birth to a newborn. After bringing the newborn home, the mother decides she is not ready to care for a baby. The mother allows the newborn to reside with a family friend. The newborn no longer resides with the mother, but the newborn is to remain on MA until age one even though the newborn is not residing with his/her biological mother.
Newborns that are initially eligible for MA or CHIP because their mother was receiving MA or CHIP at the time of birth are considered to have satisfactory documentation of citizenship and identity by the sole fact that they were born in the United States. Citizenship and identity documentation is not required at birth or at any renewal or application for MA or CHIP thereafter.
A newborn child born to a woman receiving free or low-cost CHIP should first be screened for MA eligibility
.
EXAMPLE: A pregnant 16-year old is on CHIP and her eligibility is based on her parent’s income. The baby is born and the parental income used to determine CHIP eligibility for the 16-year old is not used in an MA eligibility determination for the newborn. The 16-year old mother has no income. The newborn is eligible for MA and should not be enrolled or referred to CHIP.
CHIP Contractor Responsibilities
The CHIP contractor receives notification of birth of the newborn and screens the newborn for MA.
If the newborn is determined eligible for MA, the CHIP contractor will complete a referral through Healthcare Handshake (HCHS). The newborn should be listed as the only individual applying for MA. All other CHIP household members will be listed on the referral as not applying.
When the HCHS referral is made, the CHIP contractor should notify the CAO CHIP contact person (via email) that a referral for a newborn has been made through HCHS.
CAO Responsibilities
The CAO will pull the MA newborn referral immediately and expedite the MA opening. CHIP will cover the newborn from the date of birth to the day before the referral is made to DPW. The CAO will open MA for the newborn beginning the date of referral. The CAO has five working days to open MA for the newborn.
The CAO should include all family members listed on the CHIP referral and COMPASS summary when processing the referral. The newborn should be the only individual applying for MA.
If the mother of the newborn is unemancipated and still under the care and control of her parent, then the grandparent of the newborn is to be used as the payment name on the record.
NOTE: If the information on the CHIP referral is not sufficient to open MA for the newborn, the CAO will contact the family to obtain the information and immediately open MA for the newborn.
When opening the newborn and encountering the CAMAIN screen in CIS or the Individual Attributes screen in eCIS, the CAO will mark “Y” in CIS or check mark in eCIS for the newborn under the following:
With parent since birth.
Received MA at birth.
NOTE: “Y” must be entered in CIS or check marked in eCIS for these questions, in order for the newborn to cascade to a PS 18 category. That way, the newborn will remain eligible if during the one-year eligibility period, the parental income exceeds the income limit.
Set the renewal month to the last day of the month of the newborn’s birth.
EXAMPLE: If the child is born on May 10, 2011, the renewal date will be May 31, 2012.
· The newborn is eligible for MA until the first birthday. When the child reaches age one, the CAO will process a renewal to determine if the child remains eligible.
Health care coverage for children is one of the most important benefits provided by the MA program. The DHS wants to make sure that all children who qualify for MA can apply for and receive free health care coverage available to them.
To support this effort, the CAOs have liaisons who work with medical providers and local community agencies to increase public awareness about the benefits and services available under the MA Program. These liaisons offer help with outreach, including the following services:
Providing brochures and other materials about the MA program.
Providing MA applications.
Assisting people in filling out the MA application.
Forwarding the applications to the CAO for processing.
Outstationing is a process that allows MA applications to be taken at sites in the community other than the CAOs. Studies have shown that many families who may qualify for MA are not enrolled in the program. Outstationing is an effort to reach more children and provide for their critical health care needs.
The following are some benefits of outstationing:
People can apply for MA at the place where medical services are offered.
Providers can help MA applicants fill out applications.
The CAO may be able to process the MA application more quickly if the application is completed fully and includes the necessary documents.
The applicant can obtain benefits quickly, and the provider can get paid quickly.
Participating providers include general, psychiatric, and rehabilitation hospitals; federally qualified health centers; and other sites chosen by the DHS.
Updated December 3, 2013, Replacing February 14, 2012,