An applicant/ beneficiary or his authorized representative may request an appeal within 30 calendar days from the date on a Notice of Adverse Action. The eligibility worker must follow the policy and procedures listed in MPPM 101.13.10, Right to Appeal and Fair Hearing when a request to appeal a retroactive determination is received.
101.05.02 Claims for Retroactive Eligibility (Eff. 06/01/13)
Claims involving retroactive eligibility must meet both of the following criteria to be considered for payment:
Be received and entered into the claims processing system within six months of the beneficiary’s eligibility being added to the Medicaid eligibility system; AND
Be received within three years from the date of service or date of discharge (for hospital claims). Claims for dates of service that are more than three years old will not be considered for payment.
When the individual’s eligibility is to be established based on the factors of blindness or disability, the individual’s blindness or disability must be established for the retroactive period, if not already established.
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101.06 Posthumous Applications (Eff. 10/01/05)
An application for Medicaid may be made on behalf of a deceased person. An application for retroactive coverage can also be filed on behalf of a deceased person and must be filed before the end of the third month following the date of death.
Death is not an appropriate reason to deny an application for Medicaid benefits unless the applicant has no outstanding medical expenses subject to payment by Medicaid in the eligibility period surrounding his application.
When the applicant has incurred medical expenses before death, a full eligibility determination must be made.
101.07 Access to the Application Process (Eff. 10/01/05)
Each application intake site is required to provide services to the limited English proficient, deaf, blind, and disabled applicant to comply with non-discrimination mandates under the Civil Rights Act and the Americans with Disabilities Act.
101.07.01 Interpreters (Rev. 11/01/08)
Applicants/beneficiaries who are limited English proficient, deaf, or blind must be provided with an interpreter to eliminate barriers to applying for services offered under the Medicaid program.
The Medicaid eligibility worker must arrange for auxiliary services such as an interpreter of a person’s native language, sign language, teletypewriter, telecommunication device for the deaf, telebrailles, visual or tactile signaling devices and assisted listening devices for the blind.
If the eligibility worker determines that a language interpreter is needed, he/she must access the Language Line. (Refer to MPPM Chapter 104, Appendix Q.) With supervisory approval, the eligibility worker should contact an interpreter and arrange for the service.
For applicants/beneficiaries requiring hearing or vision interpretive services, contact the School for the Deaf and Blind at (888) 567-0980. When an invoice is received for services, indicate the contract number #A61262A on the invoice, and forward to the regional office. The regional office will then send the invoice to the Division of Local Eligibility Processing. A DHHS Form 192, Purchasing Requisition, is not necessary.
The agency has an application available in Braille. If an applicant makes a request for a Braille application, contact the Resource Center at 1-888-549-0820. An application and brochure will be made available to the individual. The date of application will be the date the individual makes the request for the application from the resource center.
101.07.02 Barriers (Eff. 10/01/05)
Access to the facility should not be a barrier. Each facility where Medicaid eligibility workers are located should have access for handicapped persons. Elimination of barriers may be accomplished by sending eligibility workers to interview the person in his home or at a barrier-free alternative site.
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101.07.04 Electronic Application for Medicare Savings Programs (MSP) from the Social Security Administration (Eff. 11/01/10, Rev. 01/01/11)
For individuals who apply for the Low-Income Subsidy (LIS) with the Social Security Administration (SSA), the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) requires SSA to forward an electronic application to the state Medicaid agency to determine if the individual may be eligible for a Medicare Savings Program (MSP). Medicare Savings Programs are ABD/QMB, SLMB, and QI. The Division of Central Eligibility Processing (DCEP) will be responsible for determining initial eligibility using resource and income information as declared on the electronic application and the DHHS Form 3306, Addendum for Medicare Savings Programs. Applications approved for ABD/QMB or SLMB will be transferred to and accepted by the appropriate local eligibility office for maintenance. At the next annual review, local Medicaid eligibility staff will be required to complete a full eligibility determination including verification of income and resources.
101.08 Standard of Promptness (Eff. 10/01/05)
Eligibility must be determined within the following timeframes.
101.08.01 FI-Related Applications (MAGI Eligibility Groups) (Rev. 10/01/13)
Federal rules require that applications be approved or denied, and the applicant notified of the decision within 45 days from the effective date of the application. The date of application is counted as the first day of the 45-day count.
For all applications, if verification is needed from the applicant, the Medicaid eligibility worker is required to complete the DHHS Form 1233 ME, Medicaid Eligibility Checklist, requesting the needed information and should allow at least 21 days for the applicant to submit the information to allow the application to be processed within 45 days.
The applicant has the primary responsibility for providing documentary evidence to support statements made on the application or to resolve any questionable information.
The eligibility worker will accept any reasonable documentary evidence provided by the applicant and will be primarily concerned with how adequately the verification proves the statements on the application or review form.
If the applicant is unable to obtain information necessary to establish eligibility in a timely manner, the eligibility worker must make a reasonable effort to assist the applicant.
Refer to MPPM 101.08.03 for MEDS Extension of Promptness procedures.
South Carolina specific standards impose the following additional requirements:
For all FI-related applications, except OCWI (Pregnant Women) and Family Planning, income must be verified before approval.
If an application is denied solely for failure to provide information, and the applicant provides all needed verifications within 30 days from the date on the denial notice, the date of the previous application must be used to determine the effective date.
If an ongoing case is closed solely for failure to provide information, and a completed signed review form with all required verifications is received within 30 days from the date of the closure notice, the case should be treated as a review and continued eligibility for the beneficiary should be determined using the information provided.
Exception: The Transitional Medicaid Quarterly Report cannot be treated as a “Review” if they are not returned by the 21st day of the month following the month in which the quarterly report was received. The beneficiary must re-apply for Medicaid.
Eligibility should be determined as if the verification was received with the first request. The case record should be documented with the date the information was received. If retroactive eligibility is requested, it should be based on the date of the previous application.
An initial budget based on the applicant's allegation of income, pregnancy, citizenship, and family circumstances must be completed on the day an application is received to determine eligibility for OCWI (Pregnant Women). If the eligibility worker cannot process the application the date received, a decision must be made by the end of the next business day, and the reason the application could not be processed must be documented in the case record. It is important that the pregnant woman has coverage to access prenatal care as quickly as possible. Refer to MPPM 203.02.02 for specific instructions on processing OCWI (Pregnant Women) applications.