Application and Decision 510-05-25

 

Application and Review 510-05-25-05

(Revised 8/1/2024 ML #3854)

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(N.D.A.C. Section 75-02-02.1-02)

 

  1. Application.
  1. All individuals wishing to make application for Medicaid must have the opportunity to do so, without delay.
  2. A relative or other interested party may file an application in behalf of a deceased individual to cover medical costs incurred prior to the deceased individual's death.
  3. An application is a request for assistance on a prescribed form designed and approved by the North Dakota Department of Health and Human Services.
  4. There is no wrong door when applying for Medicaid or any of the Healthcare coverages. The experience needs to be as seamless and with as few barriers as possible.
  5. North Dakota Medicaid applications must be maintained electronically in the case file.
  6. A prescribed application form must be signed by the applicant, and authorized representative or, if the applicant is incompetent or incapacitated, someone acting responsible for the applicant.

  • An application is considered signed if the signature is found anywhere on the application, other than to answer to answer a question.

  1. The date of the application is the date the application, is signed by an appropriate person, is received at a zone office, the Medical Services Division, a disproportionate share hospital, or a federally qualified health center. The date received must be documented.

  • Applications received electronically are considered received based on the time/date stamp

  • Applications received in person must be date stamped as received when the individual delivers it to the zone offices.

  • Applications left in a drop box refer to policy at 448-01-15-10

Note: Applications must be registered in the eligibility system as soon as possible upon receipt, but no later than the fifth day following receipt. Applications will be considered received on the day submitted.

  1. An application is required to initially apply for Medicaid, to re-apply after a Medicaid case was closed, or to open a new Medicaid case for a child who has been adopted through the state subsidized adoption program.
  2. Zone offices must accommodate any recipient requesting to have a face-to-face or telephone interview when applying for Medicaid. However, an interview is not required to apply for assistance.
  3. Information concerning eligibility requirements, available services, and the rights and responsibilities of applicants and recipient must be furnished.

 

Acceptable forms for applying for Medicaid:

  1. The Department's online "Application for Assistance", located at https://applyforhelp.nd.gov

  2. The electronic file received by the state from the Federally Facilitated Marketplace (FFM) containing the single streamlined application; or

  3. The SFN 1909 " Application for Health Coverage and Help Paying Costs"; or

  4. Telephonic applications utilizing any one of the prescribed applications; or

  5. SFN 405 " Application for Assistance"; or

  6. SFN 641, "Title IV-E/Title XIX Application- Foster Care"; or

  7. Applications provided by disproportionate share hospitals or federally qualified health centers are SFN 405 with "Hospital" stamped on the front page; or

  8. Interstate Compact on Adoption and Medical Assistance (ICAMA) for 6.01 " Notice of Medicaid Eligibility/Case Activation" stating North Dakota is responsible for the Medicaid coverage for the specific child; or

  9. SFN 958, "Health Care Application for the Elderly and Disabled". However, notification must be sent to the individual requesting information needed to make the ACA eligibility determination; or

  10. SFN 1803, " Subsidized Adoption Agreement"; or

  11. The Low-Income Subsidy (LIS) file from SSA

 

2. Review

A review requires the evaluation of all financial and non-financial requirements affecting eligibility. This will include, but is not limited to, reviewing income, household composition, health insurance coverage, and citizenship status, listed in the case file, reported, and verified on the most recent application or review form, and verifications received from all electronic sources.

 

Information that is not subject to change, such as US citizenship, date of birth, SSN, etc., does not usually need to be reviewed. However, if questionable, the information needs to be verified.

 

  1. Passive Reviews: A Passive review is the annual twelve-month review of eligibility. Information available, the case is processed, and the household must be notified of the eligibility determination and basis of eligibility.

     

  • PASSES Reasonable Compatibility- If able to renew eligibility based on the information available, the case is processed, and the household must be notified of the eligibility determination and basis of eligibility.

     

  • The individual/household must inform the agency if any of the information contained in the notice is inaccurate. The individual is not required to sign and return such notice if all information in the notice is accurate.

 

  • FAILS Reasonable Compatibility- A Passive review verification notice and pre-populated review form needs to be sent.

     

  • To complete the review, the pre-populated review form and required verifications must be returned

  • If both are not returned, eligibility will close the last day of the month in which the review is due.

  • The individual has 90 days after the termination to provide the pre-populated review form and verifications. Based on the information received, eligibility must be reconsidered to the termination date.

     

  1. Ex Parte/ Desk Reviews: A review completed when a zone office becomes aware of or has received information indicating a change.

     

Examples: adding a household member, processing a change in level of care, adding Medicare Savings Program coverage, when an ineligible household member is requesting eligibility, when eligibility is lost under a category (e.g., SSI to non-SSI, Expansion to ABD coverage), aligning review dates with SNAP or TANF.

  • When the Zone office has all information needed to determine eligibility based on a change in circumstances, a review form does not have to be sent.

  • When more information is needed to determine eligibility, a request for verification along with a pre-populated review form must be sent.

     

Additional information when completing a Review:

  • A recipient has the same responsibility to furnish information during a review as an applicant has during an application.

  • An online narrative must document the completion of the review

  • A review must be completed within thirty days after a county agency has received information indicating a possible change in eligibility status.

  • A review, using one of the forms identified, in acceptable review form section, is required to open a new Medicaid case for recipients who move from an existing case to their own case. (e.g. an 18-year-old attains age 19, moves out of the parental home, on other than a temporary basis.)

  • Zone offices must accommodate any recipient requesting to have a face-to-face or telephone interview for their review. However, an interview is not required to complete a review.

  • Reviews must be completed and processed no later than the last working day of the month in which they are due.

  • It is permissible to complete an early review of a child's eligibility for Medicaid and CHIP. However, the household may not be required to provide any information that is needed to specifically determine only the eligibility of the Medicaid and CHIP children who were determined to be continuously eligible. The family may voluntarily provide specific information but must not be required to do so.

     

If all factors of eligibility are reviewed:

  • If the child is found to be eligible for Medicaid (other than Medically Needy), eligibility must be authorized for Medicaid and the child will be given a new twelve-month continuous eligibility period.

  • If the child is found to be NOT eligible for Medicaid (other than Medically Needy), the child may not be terminated at the time of the early review unless the child meets one of the state's exceptions to terminate continuous eligibility. They would remain eligible for the reminder of the original continuous eligibility period and a review would be required at that time.

     

Acceptable forms for completing a review:

  1. A review received through the North Dakota Self Service Portal (SSP) for Medicaid

  2. System generated Review or " Monthly/Change Report";

  3. SFN 642, "TitleIV-E/Title XIX Redetermination-Foster Care" for children in Foster Care, or other confirmation from a state IV-E agency (in state or out of state) that verifies continued IV-E foster care eligibility.

  4. One of the previously identified applications; or

  5. When completing a review for children eligible for subsidized adoption assistance, receipt of one of the above review forms is required. However, the following two criteria must be verified:

    • The child remains a resident of North Dakota; and

    • The child continues to be eligible for the subsidized adoption program

    • In addition, contact should be made with the household to determine whether the child has obtained or lost other insurance.

    6.