Other Eligibility Requirements
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UPDATED: JUNE 2011 457 TABLE OF CONTENTS OTHER ELIGIBILITY REQUIREMENTS APPLICATION, CERTIFICATION AND RENEWAL ...................................................... .461 FACILITATED ENROLLERS…………………………………….…………………463 NEW APPLICATION ........................................................................................ 465 FAMILY PLANNING BENEFIT PROGRAM APPLICATION…………………... 476 MEDICARE D LOW INCOME SUBSIDY APPLICATION……………………... 478 REAPPLICATION ............................................................................................ .479 RENEWAL…………………….…………..……………………………………..…...481 DECISION AND NOTIFICATION……………………………………………………..…….. 486 ACCEPTANCE……………………………………………………………………....488 DENIAL…………………………………………………………………………….....490 WITHDRAWAL OF APPLICATION……………………………………………… 492 DISCONTINUANCE OR REDUCTION……………………………………………493 TIMELY NOTICE………………………………………………………………495 RETROACTIVE ELIGIBILITY PERIOD……………………………………………………..495.1 PAYMENT OF PAID MEDICAL BILLS ……………………………………………495.2 PAYMENT OF UNPAID MEDICAL BILLS ……………………………………….495.6 FINANCIAL MAINTENANCE…………………………………………………………………496 OWNERSHIP AND AVAILABILITY…………………………………………………………..498 AUTHORIZATION……………………………………………………………………………..504 CARD ISSUANCE .......................................................................... …………………… 506 RECIPIENT RESTRICTION PROGRAM (RRP) ..................................................... …..508 CO-PAY ......................................................................................................................... 509 (MRG) UPDATED: JANUARY 2012 458 MEDICAID BUY-IN PROGRAM FOR WORKING PEOPLE WITH DISABILITIES PREMIUM PAYMENTS………… 512 STATE RESIDENCE AND RESPONSIBILITY FOR ASSISTANCE…………………513 DISTRICT OF FISCAL RESPONSIBILITY (DFR)……………………….…..515 ASSISTANCE TO PERSONS WHO CHANGE RESIDENCY……………...524 ASSISTANCE TO PERSONS TEMPORARILY ABSENT……………….….531 ASSISTANCE TO PERSONS TEMPORARILY IN THE STATE…………...533 LIVING ARRANGEMENTS……………………………………………………………….535 LIVING IN OWN HOME………………………………………………………...538 MEDICAL FACILITIES………………………………………………………….539 PUBLIC INSTITUTIONS………………………………………………………..541 INFANTS RESIDING WITH INCARCERATED MOTHERS………………..543 MAINTAINING MEDICAID ELIGIBILITY FOR INCARCERATED INDIVIDUALS…..545 MAINTAINING MEDICAID ELIGIBILITY FOR INDIVIUALS ADMITTED TO TO A PSYCHIATRIC CENTER…………………………………………………….549.1 LEGALLY RESPONSIBLE RELATIVES (LRRs)……………………………………….550 SPOUSE…………………………………………………………………………553 PARENTS AND CHILDREN…………………………………………………..556 ABSENT PARENTS……………………………………………………………559 EMANCIPATED MINOR………………………………………………………560 IV-D REQUIREMENTS………………………………………………………..561 STEP-PARENTS……………………………………………………………….569 HOUSEHOLD COMPOSITION…………………………………………………………572 LOW INCOME FAMILIES (LIF), ADC-RELATED, PREGNANT WOMEN AND CHILDREN)………………………………….…………573 SSI-RELATED…………………………………………………………………576 (MRG) UPDATED: JANUARY 2012 459 SINGLES/CHILDLESS COUPLES (S/CC) ...................................................... 577 IDENTITY ...................................................................................................................... 578 CITIZENSHIP AND IMMIGRATION STATUS ............................................................... 589 CITIZENS ........................................................................................................ 592 NATIVE AMERICANS ..................................................................................... 605 SATISFACTORY IMMIGRATION STATUS ................................................... 608 QUALIFIED ALIENS ............................................................................... 611 BATTERED QUALIFIED ALIENS .................................................. 618 REFUGEE MEDICAL ASSISTANCE………………………………..629 U.S. ARMED FORCES ACTIVE DUTY AND VETERANS………. 634 VICTIMS OF TRAFFICKING………………………………………….636 PRUCOL……………………………………………………………………... 641 DOCUMENTATION GUIDE FOR PRUCOL……………………. …659 TEMPORARY PROTECTED STATUS (TPS)…………………………….662 OTHER VISA STATUSES…………………………………………………………665 NON-IMMIGRANTS ADMITTED ON A TEMPORARY BASIS…………..…...666 SPECIAL NON-IMMIGRANTS………………………………………………. ….669 UNDOCUMENTED/ILLEGAL ALIENS TREATMENT OF EMERGENCY MEDICAL CONDITION ........................... 672 RECOVERIES ............................................................................................................... 676 ESTATE RECOVERIES……………………………………………………………..680.1 CONFINEMENT AND PREGNANCY RELATED EXPENSES ........................... 681 LIENS………………………………………………………………………………….683 VOLUNTARY REPAYMENTS…………………………………………………….. 685 STATE AND FEDERAL CHARGES ........................................................................... .687 (MRG) UPDATED: JANUARY 2011 460 NATIVE AMERICANS AND THEIR FAMILIES LIVING ON A RESERVATION ............................................................. 689 HUMAN SERVICES OVERBURDEN ............................................................. 690 OMH/OPWDD CHAPTER 621 ELIGIBLES .................................................... 691 OFFICE OF MENTAL HEALTH (OMH) .......................................................... 693 OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES ...................................................... 695 SOCIAL SECURITY ENUMERATION ........................................................................ 697 PRESUMPTIVE ELIGIBILITY ..................................................................................... 701 NURSING FACILITY, HOSPICE OR HOME HEALTH CARE SERVICES…………………………………………………………… ….702 PREGNANT WOMEN ..................................................................................... 707 CHILDREN UNDER THE AGE OF 19 ............................................................ 710 IMMEDIATE MEDICAL NEED .................................................................................... 714 VETERANS’ AFFAIRS REFERRAL ........................................................................... 715 CONSOLIDATED OMNIBUS RECONCILIATION ACT (COBRA) ............................. 716 COMPUTER MATCHING ........................................................................................... 719 WAIVERS CARE AT HOME WAIVERS ........................................................................... 720 NURSING HOME TRANSITION AND DIVERSION WAIVER……………… .. 722 BRIDGES TO HEALTH (B2H)…………………………………………………….725 TRAUMATIC BRAIN INJURY (TBI) WAIVER……………………………………727 OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES (OPW-DD)………………………………………….………. 731 (MRG) UPDATED: JUNE 2011 461 OTHER ELIGIBILITY REQUIREMENTS APPLICATION, CERTIFICATION AND RENEWAL Description: The initial authorization and granting of Medicaid is based upon a written application, made on a “State-prescribed” form. The continuance of Medicaid is premised on a renewal of the recipient’s eligibility for Medicaid. Department Regulations and the recipient’s individual circumstances determine the frequency of recertification. Policy: Medicaid is granted initially upon the determination of eligibility, based on a written application, made on a “State prescribed” form. An application may be made by the applicant, his/her authorized representative, or when the applicant is incompetent or incapable, by someone acting responsibly on his/her behalf, such as an adult family member, or a person or agency acting on behalf of the applicant. Continuance of Medicaid is granted upon the renewal and redetermination of the recipient's eligibility. Documentation contained in the case record is evaluated during recertification and/or reapplication. A separate Medicaid eligibility determination is made when a Temporary Assistance (TA) case is denied or closed and the household applied for or was in receipt of Medicaid. The only exception is when the reason to deny, suspend, reduce or terminate Temporary Assistance is also a proper basis for denial, reduction or termination of Medicaid. A separate Medicaid eligibility determination is also made when a SSI recipient loses eligibility for SSI. Medicaid is continued until a separate eligibility determination can be made. References: SSL Sect. 366 366-a Dept. Reg. 350.1 350.3 350.4 360-2.2 360-2.3 360-6.2 ADMs 10 OHIP/ADM-4 04 OMM/ADM-6 97 OMM/ADM-2 82 ADM-5 80 ADM-19 INF 98 OMM/INF-02 (MRG) UPDATED: JUNE 2010 462 OTHER ELIGIBILITY REQUIREMENTS APPLICATION, CERTIFICATION AND RENEWAL Interpretation: An applicant for Temporary Assistance applies separately for Medicaid by indicating that s/he wants a Medicaid eligibility determination as well. An SSI recipient is granted Medicaid based upon his/her certification for SSI. When a Temporary Assistance or SSI case is closed, Medicaid is continued until a separate Medicaid determination is made. The only exception to this is when the reason to suspend or terminate Temporary Assistance is also a proper basis for the termination of Medicaid. In this case, a separate statement appears in the Notice of Intent advising the client of the action to be taken on his/her Medicaid case, the reasons for the action, the effective date of the action and the supporting regulations. The re-determination for Medicaid is completed by the end of the calendar month following the month in which Temporary Assistance is terminated. Similarly, for every SSI cash recipient whose case is closed, unless the closing is due to the death of the recipient or because the recipient moved out of state, a separate eligibility determination is made for Medicaid. If an individual wishes to apply for Medicaid only, a separate application for Medicaid is filed and financial eligibility established using the standards of income and resources,