806-2         ACTIONS TAKEN ON THE APPLICATION

Every applicant must be provided with adequate written notice of the action taken on the application. Adequate notice means that the individual is informed of the action taken, the reasons for the action, and the appropriate federal and state regulations that support the action.

806-2 A.   APPROVING THE APPLICATION

An approval notice must be sent to the household following a determination of eligibility. Same day eligibility determinations are expected whenever possible. If the application cannot be worked right away, the agency must process the application within 45 days. See section 806-2 (F) when an application is delayed.

Note:

Applications for Pregnant Women Medicaid must be processed by the fifth working day following the application date.

Eligible First Month/Ineligible Second Month: A household may be eligible for the month of application and ineligible in the subsequent month. In this case, the household is approved only for the month of application. The household’s information must then be transferred to the FFMFederally Facilitated Marketplace.

Ineligible First Month/Eligible Second Month: A household may be ineligible for the month of application but eligible in the subsequent month. Even though they are denied for the month of application, the household does not have to reapply. The same application is used for the first month denial and the determination of eligibility for the subsequent month.

Note:

The first month of the certification period is the first month the household is found eligible for assistance.

Example:

Application received 4/14/16. The individual is not eligible for April 2016 benefits, but is eligible for May 2016 benefits. The certification period is 5/1/16 - 4/30/17.

806-2 B.   BENEFIT START DATE

The benefit start date is the first day of the month that an application is filed with the agency and the agency determines the household is eligible.

The application filing date is the date an identifiable application is received in the office. Applications may be received in several ways:

1.  Online – Each online application will have a time and date stamp whether received through the SSPSelf Service Portal or the FFMFederally Facilitated Marketplace. The application filing day will be the date recorded in the time and date stamp.

2.  Paper – Paper applications may be submitted in person, received in the mail, or left in a drop box at the office.

A.  In person – the application date is the date the application is submitted.

B.  By mail – the application date is the date the application is delivered to the office. This includes applications submitted by fee agents.

C.  Drop Box – An application delivered to the drop box before 5pm will have that date as the application date. When an application is delivered to the drop box after 5pm or when the office is closed, the application received date is the following business day.

3.  Telephone – When an application is taken by phone, the application date is the date the phone call was received.

4.  Fax and e-mail - An application can be received via fax or e-mail. The application date is the business day the application is received via fax or scan. If received outside of normal office hours, the application date is the first business day after the application is received via fax or e-mail.

806-2 C.   PENDING THE APPLICATION

When all attempts to verify eligibility requirements electronically have failed and DPADivision of Public Assistance has not been able to verify information by phone, the application must be pended for information needed to determine eligibility. DPADivision of Public Assistance cannot pend for information already given to the FFMFederally Facilitated Marketplace. A notice that clearly informs the applicant what is needed to complete the application must be sent. Applicants will be given at least 10 days, but no more than 30 days, from the date of this notice to provide the verification. Refer to Administrative Manual section 104-4 B for guidelines.

Applicants contacting the agency within the pend period expressing difficulty in obtaining required verification will be offered assistance. The ETEligibility Technician must extend the pend period if additional time is needed to obtain the information. A new pend notice must be sent.

806-2 D.   DENYING THE APPLICATION

A denial notice must be sent to the applicant explaining the reason for the denial. This notice should be sent as soon as possible following the determination of ineligibility, but no later than 45 days following the application filing date.

Applicants denied for failing to provide needed verification by the end of the pend period will be sent a notice of denial at the end of the pend period. If the applicant provides the verification after the pend period but within 45 days of the application filing date, the ETEligibility Technician must accept the verification and make an eligibility determination without requiring a new application. If the household is found eligible, the ETEligibility Technician will use the original benefit start date.

Note:  

When the deadline for processing an application or providing verification does not fall on a workday, it will be extended to the next workday.

If a household is found ineligible for MAGIModified Adjusted Gross Income Medicaid, the application will be forwarded to the FFMFederally Facilitated Marketplace for a further determination of healthcare options.

806-2 E.   WITHDRAWING AN APPLICATION

The applicant may voluntarily withdraw the application at any time before the eligibility determination is made.

A written, signed and dated request to withdraw an application for Medicaid is mandatory. The written request can be provided by being brought in, faxed in, mailed in or emailed since electronic signatures are acceptable. The applicant must be given 10 days to provide the requested information. If the information is not provided within the pend period, the case will be denied due to failure to provide requested information.

The reason for withdrawal (if known) must be documented in the case note. The applicant must be advised of his or her right to reapply at any time by submitting a new application. A notice must be sent to the individual denying the withdrawn application.

See MAGI MS 806 for application signature requirements.

806-2 F.   DELAYED APPLICATION

If a household's eligibility has not been determined or benefits have not been authorized to an eligible household by the 30th day following the application filing date, the application is delayed. The ETEligibility Technician will determine the cause for the delay and take appropriate action:

1. Agency-caused delays

Includes cases where the application was not approved, denied or pended within the allowable time limits. 

If an eligibility determination cannot be made by the 45th day from the application filing date because of action required by the agency, the case is left in a pending status. The household must be sent a pend notice by the 45th day.

An application can be used for more than month of application and the following month when there is an agency caused processing delay and a notice of eligibility or ineligibility is not sent by the 45th day. Please note that using the application for more than two months is only allowed when there is an agency caused delay in processing and we are already past the two month period.

2. Household-caused delays

Includes situations where the office cannot take further action on the application without an action from the household.

If the household fails to submit the required information by the 45th day from the application filing date, the application is denied.

If the application is not denied timely and information is received from the client after the due date but prior to the agency denying the application, the agency will use the information received to determine applicant eligibility.