Family and Children's Medicaid MA-3215 Processing the Application

IV. Reopened Denials, Withdrawals, approvals or inquiries

Any time it is determined that an individual was discouraged, that an application was improperly or incorrectly denied or withdrawn, or that a state or local appeal decision reverses the denial of an application or the termination of a case, the county must take action to reopen the application or case. Additionally, some terminated cases may be reopened administratively when certain criteria are met. This section outlines the procedures to follow to reopen applications or cases.

A. Discouragement

1. Discouragement can occur with or without a signed application and can be discovered in several ways including a report by the applicant or potential applicant, through a second party review, or by the application monitor.

2. When discouragement is alleged, review the case record. If the case documentation shows that retroactive benefits, coverage for minor children and/or dual eligibility were offered and declined or that the client was afforded the opportunity to apply but declined, no discouragement occurred and no further action is required.

3. When the agency learns from any source that an individual has been discouraged and the allegation cannot be refuted based on record documentation, follow the procedures in IV.B. to reopen the application.

B. Reopening Denials, Withdrawals, and Approvals

A reopened application refers to an application that was originally denied or withdrawn but the denial or withdrawal is incorrect, improper or reversed. It can also refer to an application or inquiry when there is evidence of discouragement. The agency must re-assess the denial, withdrawal or inquiry and protect the original date of application for processing time.

1. An application must be reopened within 5 days as a result of any of the following:

a. Local or state appeal reversal, or

b. Remanded appeal by the local or state hearings officer, or

c. Improper denial or withdrawal found by the county, monitors, or Medicaid Program Representatives, or

d. Misapplication of policy (incorrect denial), or

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(IV.B.1.)

e. Discouragement.

2. Follow these procedures when reopening an application due to local/state appeal reversals, improper denials or withdrawals, remanded appeals, incorrect denials, or discouragement with a signed application.

a. A signed application is not required.

b. Key the DSS-8124 screen:

(1) Local/State Appeal Reversals or Remanded Appeals

Key the DSS-8124 within 5 workdays of the date the Notice of Decision is final. The date of application is the reopen or current date.

(2) Improper Denials/Withdrawals or Discouragement

Key the DSS-8124 on the date the agency learns of the improper denial/withdrawal or discouragement. The date of application is the date the agency learns of the improper action or discouragement.

(3) Incorrect Denials

Key the DSS-8124 on the date the agency learns of the incorrect denial. The date of application is the reopen or current date.

c. Complete the date screen. Refer to the instructions in the EIS-2400.

d. Review the case record for missing information.

(1) Local/State Appeal Reversals or Remanded Appeals

For appeal reversals or remanded appeals, review the case record according to the hearing decision, considering additional information and/or policy as instructed in the decision.

(a) If no additional information is needed, dispose of the application within five workdays of reopening the case.

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(IV.B.2.d.(1))

(b) If additional information is needed from the individual or a third party, including medical bills to meet the deductible, follow procedures in MA-3210, Verification Requirements for Applications and MA-3215, Processing the Application.

(c) Process the application within 5 workdays of receipt of the last piece of required information.

For remanded appeal decisions, the application disposition decision may be the same as or different from the original decision.

(2) Improper Denials/Withdrawals, Incorrect Denial or Discouragement

(a) If no additional information is needed, dispose of the application.

(b) If additional information is needed from the individual or a third party, including a disability determination or medical bills to meet the deductible, follow procedures in MA-3210, Verification Requirements for Applications and MA-3215, Processing the Application.

(c) If all necessary information (except a disability determination or medical bills to meet the deductible) is not received, deny the application on the 13th calendar day after the second request for information or once the application has pended a full 45 days, whichever occurs later.

1) To determine if the application has pended the 45 days, subtract the number of days the original application pended from 45. The difference is the number of days the reopened application must pend to meet the 45-day requirement. Do not include any days the application was closed.

2) For example, an MAF application dated June 10th was improperly denied on June 25th. The original application pended a total of 15 days. On August 30th, an administrative DSS-8124 was entered to reopen the application. The reopened application must pend for at least 30 calendar days (September 29th) or until 13 calendar days after the second request for information, whichever is later.

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(IV.B.2.d.(2)(c))

3) If the application has not pended a total of 45 days, hold the application until the 45th day.

(d) If all necessary information (except a disability determination or medical bills to meet the deductible) is received, and the anticipated medical expenses are within $300.00 of meeting the deductible continue to pend the application for up to 6 months.

1) To determine if the application has pended 6 months, subtract the number of days the original application pended from 180. The difference is the number of days the reopened application must pend to meet the 6 month requirement. Do not include any days the application was closed.

2) For example, a MAF application dated June 10th was improperly denied on June 25th. The original application pended a total of 15 days. On August 30th, an administrative DSS-8124 was entered to reopen the application. A review of the case record indicates that anticipated medical expenses are within $300.00 of meeting the deductible and this is the only information needed to complete the application. The reopened application must pend for at least 165 days (February 11th) or until 13 calendar days after the second request for information, whichever is later.

(e) If all necessary information (except a disability determination or medical bills to meet the deductible) is received, and the anticipated medical expenses are not within $300.00 of meeting the deductible, deny the application.

C. Discouragement Without A Signed Application

Follow these procedures to reopen a case when cited for discouragement and there is no signed application.

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(IV.C.)

1. Send the DMA-5097/DMA-5097S Request For Information, to the individual scheduling an appointment to complete an application along with a letter explaining that it has been determined that he has been discouraged and that eligibility will be evaluated back to the date of discouragement.

2. If you can determine from the case documentation that the individual was discouraged from applying enclose the application form with the DMA-5097/DMA-5097S

Instruct the individual that he can either keep the scheduled appointment or return the completed application form by the appointment date.

3. If the individual fails to keep the scheduled appointment or if applicable, does not return the application form, send another DMA-5097/DMA-5097S to schedule a second appointment. There must be at least 12 calendar days between the two appointments.

a. If the individual fails to keep the second scheduled appointment or if applicable, does not return the application form by the second appointment date, no other action is needed.

b. If the individual does file an application by the established deadline, follow procedures in IV.B.2. to key and process the reopened application.

c. If the application form is received after the 12-12 date, the date of application is the date the completed form is received. Do not treat as a reopened case due to discouragement.

D. Reopening Terminated Cases

1. Certain actions that require entering a DSS-8124 in EIS may be done administratively. A signed application is not required and a “Y” must be entered in the administrative field of the DSS-8124. Application processing time standards do not apply. These actions include:

a. Moving an individual from one case to another, in the same or different aid program/categories, or

b. Posting eligibility to a terminated case, or

c. Reopening cases terminated in error, or

d. Reopening a terminated case as the result of a state/county appeal reversal or remanded appeal. See MA-3430, Notice and Hearings, or

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(IV.D.1.)

e. Reopening Medicaid terminations. See 3.

2. Follow instructions in EIS-2012 for processing administrative actions.

3. To reopen terminated Medicaid cases follow these procedures.

a. All of the following criteria must be met for a terminated case to be reopened. If these criteria are not met, the individual must reapply for Medicaid.

(1) The case must have been terminated for one of the following reasons:

(a) Failure to complete a redetermination of eligibility,

(b) Unable to locate the recipient(s) in the case,

(c) No eligible child in the home,

(d) The recipient(s) in the case moved out of state,

(e) The recipient(s) in the case became a resident of a public, non-medical institution.

(2) The request to reopen the case must be received no later than the 10th calendar day of the month following the month of termination. The request may be made in person, by telephone call, in writing, or by receipt of information needed to complete the review.

NOTE: If the 10^th calendar day falls on a non-workday, allow the individual until the next work day to request his case be reopened.

(3) All information needed to reopen the case must be received by the 10th calendar day of the month following the month of termination.

This includes, but is not limited to, the re-enrollment form and any required verifications. If reopening a NC Health Choice case with a fee, always allow the individual ten calendar days to pay the fee.

If notice of a fee was provided prior to the case terminating, the individual has until the 10^th calendar day of the month following the month of termination to pay the fee.

(4) All of the individuals included in the case when it was terminated must be included in the reopened case.

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(IV.D.3.a.)

(5) All of the individuals included in the case must continue to live in the county that had responsibility for the termination.

(6) The individuals must be eligible in the same aid program/category as the terminated case.

b. Verify that eligibility continues.

(1) If the case was terminated for failure to complete the re-enrollment, gather all the required information and follow verification requirements in MA-3420, Re-Enrollment.

(2) If the case was terminated for unable to locate, no eligible child in the home, moved out of state, or residency in a public institution, accept the client’s statement as verification of current residence/living arrangement for the household.

c. Reopen the case.

(1) Enter the DSS-8124 screen. Key a “Y” in the administrative field.

(2) The date of application is the first day of the month following the effective date of the termination. Do not key the DSS-8124 screen into the system until the month following the month of termination.

(3) Enter the certification period as follows:

(a) When reopening a case that was terminated at the end of a certification period and a review is being completed, begin the certification period with the month following the effective date of the termination.

(b) When reopening a case that was terminated during the certification period, the certification begin date is the first day of the month following the month of termination. The certification end date is the end date of the certification period in the original case.

For example, a case being reopened was originally certified from January 1 through December 31. The case was terminated effective June 30. Reopen the case with a certification period of July 1 through December 31.

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(IV.D.3.c.(3))

(c) When reopening a medically needy case with a deductible, do not re-compute the deductible if the certification period entered is less than six months unless there was a change in income.

(4) The Medicaid status must be A (authorized). If the case cannot be authorized because the deductible has not been met, hold the application pending until the end of the certification period.

Timely notice is required prior to denying the administrative application at the end of the certification period.

(5) The Medicaid effective date must be no earlier than the first day of the month following the month of termination. If eligibility is needed for an earlier period, use the DB/PML screen.

d. If, at any time during the reopening process, it is determined that the case cannot be reopened because it does not meet the criteria in IV.D.3.a., a signed application is required.

(1) The date of application is the date of the face-to-face interview or the date the base document is signed.

(2) Follow all requirements for an application.

(3) The application does count in the county’s report card.