Family and Children's Medicaid MA-3205 CONDUCTING A FACE-TO-FACE INTAKE INTERVIEW

V. TAKING THE APPLICATION

After discussing the individual’s situation and describing his options, the individual will need to decide whether he wants to continue with the application process or stop.

A. Inquiries and Withdrawals

1. Inquiry

If the individual decides at any time prior to signing the application or the base document used to determine eligibility that he does not want to apply for assistance, complete an inquiry. Always explain to the individual his right to apply on that day and if he decides not to apply that he may apply at any time. Document that this explanation was given.

The following must be included with each inquiry:

a. The DMA-5094/DMA-5094S, Notice of Right to Apply for Benefits, and

b. A completed DMA-5095/DMA-5095S, Medicaid/Work First Notice of Inquiry, which includes the following information:

(1) The date.

(2) The individual’s name and, if applicable, the representative’s name, address and telephone number.

(3) The specific reasons why the individual decided not to apply for assistance.

(a) Include all facts relevant to the individual’s situation that support the decision not to apply (for example, age, income, medical bills, etc.).

If the individual decides to wait and apply for retroactive assistance because of the ongoing deductible amount, explain the timeframes for requesting retroactive assistance and the residence and resource requirements during the retroactive period. Clearly document the record that this explanation was given.

(b) If the individual refuses to give a reason for not making the application, document the refusal to explain.

Document on the DMA-5095/DMA-5095S, Medicaid/Work First Notice of Inquiry any other programs that were discussed or to which the individual was referred. Include information regarding the Medicare Low Income Subsidy program, (LIS). See MA-2309, LIS Application For Medicaid, in the ABD Medicaid Manual.

REISSUED 12/01/10 – CHANGE NO. 16-10

(V.A.1.)

c. Give the original DMA-5095/DMA-5095S, Medicaid/Work First Notice of Inquiry to the individual. Keep a copy for the agency file.

2. The individual may decide after signing the application or the base document that he does not want to continue the process. In this case, the application must be withdrawn. See MA-3215, Processing the Application, for instructions for completing the withdrawal.

B. Date of Application

The date of the application is the date the application form or base document is signed. This rule applies regardless of where the interview takes place (in the county DSS, at an outstation, or in a county DSS outside of the individual’s county of residence). See MA-3207, Receiving Mail-in Applications, regarding the date of application for mail-in applications.

C. Completing and Signing the Base Document

1. Complete one base document for all applicants in the same household requesting MAF, MIC or MPW.

2. Complete the base document as thoroughly as possible during the interview.

3. Have the individual or his representative sign the base document to verify:

a. He answered truthfully to the best of his knowledge, and

b. He understands his rights and responsibilities as an applicant/recipient, and

c. He authorizes the investigation of his eligibility for assistance by the county department of social services, the State Division of Medical Assistance and the United States Department of Health and Human Services.

D. Entering the Application into the Eligibility Information System (EIS)

Key the application into EIS within three workdays of it being signed.

REVISED 11/01/11 – CHANGE NO. 18-11