Medical Assistance (MA) Fast Track Enrollment Enhancements, OPS170805 (Published August 30, 2017)
The application process starts when an individual or someone acting for him or her files a signed application or submits a COMPASS application.
Exception:
Under some circumstances, a new application is not required. See
Chapter 379.
Exception: See Chapter 317 for BCCPT application procedures.
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 DHS or online through COMPASS. When the application is submitted by a provider or site designated by the DHS, 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.
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
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.
NOTE: An MA 314 Form is not required for provider applications submitted through COMPASS.
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.
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 600HC. 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 600HC
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)
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.
Providers listed in Appendix
A or Appendix B and Community Partners
listed in Appendix C (or
any site designated by the DHS) 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.
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 PA-BCCEDP BCCPT applications.
Individuals may submit healthcare applications through the State-Based Exchange (SBE). If the SBE assesses an individual as potentially eligible for MA, the SBE electronically transfers the application to the Department of Human Services (DHS).
SBE applications, like regular COMPASS healthcare applications, are processed through COMPASS Real-Time Eligibility (RTE) and may be auto-opened.
SBE applications that cannot be auto-opened through the COMPASS RTE process are sent to the CAO for processing. The CAO must complete a full eligibility determination for all individuals listed in the Applicant Information section. SBE applications may be auto-rejected through COMPASS RTE and no additional action is required by the caseworker.
The MA eligibility begin date for SBE applications is the date the application was submitted to the SBE.
NOTE: An SBE application is signed when the application is submitted through the SBE. No additional signature is required.
When processing SBE applications, the CAO must:
Review and process the application to determine eligibility, if the necessary information is provided on the application or information can be obtained through data sources or an existing case record.
Information on SBE applications must be verified in accordance with the current verification policy in Chapter 378.
NOTE: The CAO will review MA for all individuals listed under the “Applicant Information” section on the first page of the SBE application.
Request additional information or verification from the individual only if needed. The CAO must not request duplicate information or documentation.
Process the application within 30 calendar days of the SBE transfer date. If a determination cannot be made in 30 days, the CAO must send a notice to the applicant explaining why a determination cannot be made and saying that the 30-day period will be extended to 45 days.
NOTE: The reconsideration period for SBE applications follows the policy for MA applications outlined in Chapter 379.1.
The CAO must process every SBE application because a response to the SBE is required for each application. The system reviews SBE applications to determine if a previous one was received. If a previous SBE application was received within 180 days, the system identifies the differences between the transfers and allows processing through Case Maintenance.
“SBE Update” is a work item on Workload Dashboard, and on the Case Summary screen in Case Processing. The work item alerts a worker that an SBE Update has been received and needs to be processed. The caseworker can select the work item and view a “Difference Comparison”. The Difference Comparison identifies differences between the current SBE application and the previous application (up to 180 days old) for the caseworker to determine if any updates are needed.
NOTE: Any case changes that have been made between the time period of receipt of the two applications may not be reflected.
If the information on the SBE Update requires an A# for processing, the work item will give the caseworker an option to create an A#. If this option is chosen, the application is forwarded to a clerical worker to have an A# assigned.
If multiple SBE Updates are received, the caseworker may process multiple SBE Updates within a single workflow. At the end of processing, the caseworker is presented with the option to adjudicate the SBE Updates.
NOTE: The number of individuals listed as applying on the SBE Update must match the number of individuals selected for MA processing on the Individual Program Request screen.
If multiple SBE Updates are received, and a child is now in the household who may be CHIP eligible, the updates must be processed separately. This is to ensure that Health Care Handshake is completed and that the proper response is sent to the SBE.
When individuals are determined ineligible for MA, the applications may be transferred to the SBE for evaluation for other insurance affordability programs to include Advanced Premium Tax Credits and Cost Sharing. The Insurance Affordability Eligibility Summary screen displays a referral code for each individual on the application. For individuals whose applications are to be transferred to the SBE, the “S - SBE Referral” code is displayed.
The status of SBE applications can be checked through the Case Management (CM) Inquiry Menu in eCIS.
Individuals whose applications are transferred to the SBE receive a notice informing them that they have been referred to the SBE. The notice is automatically generated by the system and requires no caseworker action.
304.244 Federally Facilitated Marketplace (FFM) Applications
Prior to the transition to SBE/Pennie, the Federally Facilitated Marketplace (FFM) was the Health Insurance Marketplace for Pennsylvania. CAOs will continue to receive FFM applications in certain scenarios. CAO staff will review all individuals listed for both MAGI and non-MAGI MA eligibility, using policy outlined in MAEH 304.24 through MAEH 304.243.
Updated October 31, 2022, Replacing February 7, 2022