The CAO must make a determination of eligibility within 30 calendar days of the date a completed, signed application is filed unless the application is a COMPASS application. For COMPASS applications, the eligibility determination must be made within 30 days of the date the COMPASS application is submitted. 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.
PMA17609304 Processing Time Frame and Reconsideration Period for Federally- Facilitated Marketplace (FFM) Applications July 2015
PMA17609304 Processing Time Frame and Reconsideration Period for Federally- Facilitated Marketplace (FFM) Applications Revised September 16, 2015
Exceptions:
A determination for Healthy Beginnings must be made within 45 days of the opening date for presumptive eligibility.
See Section 317.6, Determining Eligibility for how much time is allowed for processing of Breast and Cervical Cancer Prevention and Treatment (BCCPT) applications.
At application, the CAO must record the following information in the case record:
55 Pa. Code § 125.74 55 Pa Code § 125.84
Any information that should be on the application form but is not.
The date and place of the interview if an application interview was necessary.
Another explanation, if needed, of why the individual is applying, in addition to the reasons stated on the application form (for example, past management)
Any plans made with the applicant.
An explanation of why there is different information stated on the application compared with the information in the case record.
The application process ends when any one of the following occurs:
The applicant withdraws his or her application.
The applicant is found to be ineligible.
The applicant is found to be eligible and benefits are allowed.
The CAO must send the Notice to Applicant to the individual when a determination of eligibility is made. If a provider submitted the application, the CAO must also send copies to the provider. If the individual is eligible but owes money as a patient to one or more providers, the CAO must send copies to each provider to whom the individual is responsible for making a payment.
An applicant may withdraw his or her application at any time prior to the eligibility determination is made.
55 Pa. Code § 125.84(e)(2)(iii)
NOTE: The CAO must discuss any misunderstanding of MA requirements or agency procedures with the applicant to prevent him or her from unwisely or unnecessarily withdrawing his or her application.
If the applicant withdraws the application, the CAO must take the following actions:
Have the applicant complete and sign a Voluntary Withdrawal Form (PA 1829) or provide a written statement. On the PA 1829:
Check the program(s) from which the applicant is withdrawing.
Get the applicant's signature and record date.
Record in the "Comments" section the reason for withdrawal, if the applicant gave a reason.
NOTE: A PA 1829 is preferred to document the applicant's voluntary withdrawal, but if the applicant submits a written statement the following should be included in the statement:
List the person(s) in the household and programs(s) from which they are withdrawing.
Reason for withdrawal.
Applicant's signature and date.
Deny MA, using reason code 063.
Reject the application in eCIS.
record in the case comments the reason for withdrawal, if a reason was provided.
Send a Notice to Applicant that the applicant was denied because of the withdrawal request.
If the applicant is determined ineligible prior to the application the CAO must correctly deny the application for program ineligibility and send proper notice. See Section 304.52.
If the applicant is found ineligible, the CAO must take the following actions:
PMA17361304 Verification of Income October 30, 20104
Deny MA, using the correct reason code.
Record the appropriate information and reason for denial in the case record.
Send a Notice to Applicant to let the applicant know that he or she is not eligible. Send a copy to the provider if needed.
The applicant is responsible for providing, to the extent that he or she can, the required proof to show that he or she is eligible. The CAO will not deny eligibility for lack of proof if the individual cooperates but does not obtain proof for reasons beyond his or her control.
The CAO will help the applicant, if necessary, to obtain the required proof or make a reasonable plan with the individual to obtain proof on his or her own.
If the applicant does not cooperate in providing the necessary verification, the CAO must take the following actions:
Deny MA, using reason code 042 for the denial.
Send a Notice to Applicant that includes:
What information was not provided or what action was not taken.
The regulation that required this information or action.
What actions the CAO took to help in obtaining this information.
Send a copy of the Notice to Applicant to the provider.
Authorization of benefits is the process of completing and processing all of the data necessary to approve MA benefits on CIS/eCIS.
When the CAO receives a complete MA application and approves it, the CAO must take the following actions:
Explain the type of benefit provided and how eligibility was found.
Explain the services covered by the type of benefit being allowed and any copayments or GA-related deductible requirements. (See Chapter 338, Appendix D and Section 338.522.)
Explain that the ACCESS card will be mailed, when to expect it, and how to use it when the individual receives it.
NOTE: The individual should receive the ACCESS card within 7 calendar days.
Find out if any member of the applicant/recipient group needs immediate medical care. If so, provide a Temporary Access Card (TAC) (See Chapter 380, Issuing the ACCESS Card.)
Explain that a third-party medical resource (such as insurance) must be used before MA.
If asked to help the individual find medical care, access MA CARES and give the individual a list of providers who participate in the MA Program. (See Chapter 338, Medical Assistance Benefits.)
Explain SNAP.
Give referrals to the EPSDT, DAP, LIHEAP, WIC, and PACE programs, as appropriate.
Discuss other social services that are available.
Discuss the responsibility of the recipient for reporting changes.
Between January 1 and June 30 of each year, send an Income Tax Refund Notice (CM 126) to all approved individuals who had income in the previous year. After June 30, provide the CM 126 to eligible individuals who continue to expect an income tax refund.
Enter all information required for the approval process into the computer system.
Send a Notice to Applicant to let the individual know what type of benefit has been approved, the date eligibility begins, and the amount, if any, that the patient must pay for an unpaid medical expense. Send copies to the provider.
A medical emergency is when a physician or another medical professional under the physician’s supervision (for example, a physician’s assistant or certified nurse practitioner) tells an individual that the individual has a problem that can cause serious injury or death. Proof of an emergency medical condition can be:
A statement on a prescription pad or on the provider’s letterhead.
Completed DHS forms.
A phone call from the provider.
When an individual applies for MA and says that he or she has an emergency medical condition, the CAO will take the following actions:
Speed up the processing of the application. Staff will process an application as soon as possible, within five business days after the date of request.
NOTE: If the application shows that it is an emergency, the date the application is received in the CAO is considered the date of request. If the individual contacts the CAO either in person or by phone about a pending MA application and states there is an emergency, the contact date is the date of request.
Review all available electronic data sources to verify information reported on the application. If all verification is available and reasonably compatible (See Chapter 378, Verification), authorize MA. If it is not available or reasonably compatible:
Call the individual right away if more information or proof is needed.
If the individual cannot be reached by phone, send a letter to the individual asking for the needed information or proof. The letter should go out on the same day the application comes in.
Help the individual if he or she cannot provide the needed information or proof.
Request proof of the emergency medical condition from the medical provider.
If all needed information and proof is received and the individual meets all the requirements, authorize MA.
NOTE: If the CAO has all proof needed for deciding on eligibility for the individual with an emergency, they will make the decision. The CAO will not hold back the decision while waiting for proof for any other household members who are applying.
Inform the individual whether he or she is eligible for MA.
Send
a notice telling the individual whether he or she is
eligible for MA.
Example: Mr. James submits an application for MA for himself and his son. Mr. James indicates on his application that he has an emergency medical situation and provided all needed proof for himself. For his son’s MA, Mr. James is trying to get his son’s proof of child support from his ex-wife. The CAO finds Mr. James eligible and approves benefits before it gets the proof for his son.
The applicant’s medical condition may make it hard for him or her to get needed proof. Staff will assist the individual whenever possible, but they will not authorize MA without all needed proof.
The CAO will have a way to identify every emergency MA application so that it can process the application as quickly as possible. If the CAO is not sure an individual’s case is an emergency, it will process the application as if it were an emergency. If the CAO finds out the case is not an emergency, it can treat the application as a normal one.
Non-citizens without documentation and temporary non-citizens can be reviewed for emergency MA eligibility. (See Section 322.34, Emergency Medical Services).
Example: Mr. Jones submits an application on Wednesday, January 2nd. He provides verification from a doctor that he has surgery scheduled for Thursday, January 10th, to correct a medical condition. The medical condition is not life threatening now, but it will become so if it is not treated. His surgeon refuses to perform the surgery without proof that Mr. Jones has medical coverage.
The CAO caseworker contacts Mr. Jones by telephone on January 2nd and requests proof of Mr. Jones’s income and resources. Mr. Jones turns in the proof on January 3rd. The CAO worker processes the application and sends Mr. Jones a notice of eligibility for MA on January 3rd. The worker also calls Mr. Jones to tell him of the decision the same day.
Updated August 18, 2022, Replacing June 14, 2016