2060 ABD Medicaid Application Processing

Georgia State Seal

Georgia Division of Family and Children Services
Medicaid Policy Manual

Policy Title:

ABD Medicaid Application Processing

Effective Date:

September 2024

Chapter:

2050

Policy Number:

2060

Previous Policy Number(s):

MT 72

Updated or Reviewed in MT:

MT-73

Requirements

The ABD Medicaid application process begins with the receipt of a signed application for medical assistance and ends with written notification to the applicant/recipient (A/R) of the eligibility determination.

Basic Considerations

Eligibility for ABD Medicaid Classes of Assistance (COA) is determined in the following order:

  • FBR COAs

  • LA-D/ Medicaid Cap COAs

  • Q-Track

  • ABD Medically Needy

QMB and SLMB may be approved while an eligibility determination for FS, TANF or another Medicaid COA is pending. A Medicaid member cannot be dually eligible for QI-1 and another Medicaid COA with the exception of AMN Spenddown.

Procedures

Application Requirements

The application date is the date a signed application is received by any county DFCS office. An application for any ABD Medicaid COA may be processed from any of the following application documents:

  • Form 297 Application for TANF, SNAP, or Medical Assistance

  • Form 508 SNAP, TANF, Medical Assistance Renewal Form

  • Form 632 Presumptive Eligibility (PE) for Pregnancy

  • Form 632H Qualified Hospital Presumptive Eligibility Application

  • Form 632W Presumptive Eligibility (PE) Women’s Health Medicaid Application

  • Form 700 Application for Medicaid & Medicare Savings for Qualified Beneficiaries

  • Form 94 Medicaid Application

  • Form 94A Medicaid Streamlined Application

  • Federally Facilitated Marketplace (FFM) application

  • Gateway Medical Assistance Online Application

  • Gateway Medical Assistance Renewal

  • Low Income Subsidy Application – SSA 1020B (LISA- application for Medicare Part D)

  • PeachCare for Kids® Application (Obsolete as of 09/2017)

  • Provider Portal Online Application

  • SSA Model Medicare Savings Plan (MSP) application

  • SUCCESS Application for Assistance (AFA) (Obsolete as of 09/05/2017)

  • Women’s Health Medicaid Review Form (Obsolete as of 12/2022)

A completed application consists of a signed (not typed name on signature line) application with information sufficient to contact the A/R or AREP. The signature does not necessarily have to be that of the A/R. Any other information that is missing, incomplete or otherwise unclear may be obtained from the A/R or AREP after the signed application is received and registered in the system by the agency.

A new signed application is required in the following situations:

  • Adding a program for an A/R who has been an ineligible spouse in an active Medicaid AU and who is now requesting Medicaid for him/herself under a different COA from a recipient spouse.

  • An application was previously correctly denied due to failure to provide required verification. A/R wants to reapply in a subsequent month. Although the application date of the first application is protected, have the A/R sign another application for the subsequent month(s) unless there is good cause for not initially providing the verification.

  • An application was previously correctly denied due to not meeting a basic or financial eligibility criteria. A/R now meets these criteria. Have the A/R complete and sign another application for subsequent month(s).

A new application is NOT required in the following situations:

  • If the system denies the application because the worker has not acted timely on the case

  • If the A/R is already a Medicaid recipient and is changing to another COA, a continuing Medicaid determination (CMD) is being completed or if an SSI recipient is entering a NH

  • If a current Medicaid recipient is being added as a recipient to an existing Medicaid AU, such as SSI added to Q-Track or Q-Track added to AMN

  • A non-Medicaid applicant (NM, NA, etc.) is added to an existing Medicaid AU, even if the AU trickles to a lower COA or the spenddown amount is increased.

Application Screening

Screen the application to determine the following:

  • Current receipt of the benefits for which the A/R is applying

  • Current receipt of other benefits available through the agency.

Interview Requirements

A face-to-face (FTF) interview is not a requirement for any Medicaid COA. At the eligibility worker’s (EW) discretion or the request of the A/R or AREP, a FTF interview may be scheduled; however, an application may not be denied for failure to appear for an interview.

A telephone interview is required for ABD LA-D COAs and Adult Medically Needy (AMN) COAs.

Case Worker will attempt to reach the A/R or AREP by conducting two unscheduled telephone attempts prior to scheduling an interview.

The A/R is the primary source of information for him/herself. The A/R may authorize an AREP to apply, interview and provide information on his/her behalf. An elected AREP may have verbal or written designation. If the designation is written, the applicant’s signature is required. However, because the A/R is considered the best source of information, s/he must be contacted to confirm that the information obtained is correct. This may be accomplished either by telephone, by mail, fax or in person, unless contact with the A/R is precluded by physical or mental limitations.

Information necessary to complete an eligibility determination may be obtained by any of the following methods:

  • telephone call

  • mail

  • FTF interview

  • home visit

  • secure e-mail

  • facsimile

Orally or in writing, inform the A/R about the Medicaid program(s) for which s/he may be entitled. Provide relevant information pamphlets or other printed material.

Explain the following information to the A/R and/or AREP:

  • Services provided by DFCS and the right to apply for them

  • Requirements of eligibility and the A/R’s responsibility to provide information to establish eligibility and benefit level, including the following:

    • basic eligibility requirements

    • financial requirements

    • periodic renewals

    • timely reporting of changes

    • assignment of TPL

    • medically needy requirements, if applicable

    • vendor payment/cost share, if applicable

  • The applicant’s right to the following:

    • a fair hearing

    • prompt action within the standard of promptness (SOP)

    • confidentiality

    • non-discrimination in the processing of the application

    • services available to the family from other agencies

Mandatory Forms

Complete the mandatory forms below when processing an ABD Medicaid application. Refer to Chart 2060.1 in this section.

  • Application for assistance

  • Form 297A, Rights and Responsibilities (only if Form 297 is used to apply)

  • Form 5460 - Notice of Privacy Practices (HIPAA)

    Notice of Privacy Practices and Form 297A may be mailed to the applicant. The applicant is NOT required to sign and return either form, provided the case record is documented that these forms were sent.

  • Form 216 - Declaration of Citizenship (conditionally mandatory, please see Note below)

    This form is not required if 94 (rev. 5/10 or later), Form 94A, 297, 508 (Rev. 5/12 or later), 700 (Rev.11/09 or later), Gateway Medical Assistance application, or FFM application are used as they contain the required language to meet the needs of the declaration.

  • Form DMA 285, Third Party Liability Health Insurance Questionnaire, when the person has other health insurance coverage. See Section 2230 - Third Party Liability for requirements.

    A DMA 285 is not required when application is made for QMB, SLMB, or QI-1 via Form 700. Send a copy of Form 700 to DCH/TPL in lieu of Form DMA 285 if the client has medical insurance. Attach a copy of the insurance card, front and back, if available.

Other Required Actions

Complete any other forms as necessary depending on the COA and the A/R’s circumstances.

Determine if the A/R meets all points of eligibility.

Complete mandatory clearinghouse requirements.

Follow appropriate documentation standards for ABD Medicaid.

Explore Medicaid eligibility for the three prior months.

Obtain required verification.

For LA-D A/Rs whose income exceeds the Medicaid Cap, provide the following as a handout to the A/R or AREP:

Standard of Promptness (SOP)

Eligibility should be processed as soon as all verification is received, this should take no longer than the following time frames:

  • 45 calendar days beginning with the application date for aged or blind applicants.

  • 90 calendar days beginning with the application date for disabled applicants whose disability that has not already been established by Disability Adjudication Section (DAS) for the Social Security Administration (SSA) or the State Medical Eligibility Unit (SMEU)

  • 10 working days beginning with the application date for all Q-Track applicants.

The standard of promptness is 90 calendar days when a disability decision is required before the eligibility determination can be completed. However, if a separate disability decision is not required, the 45-calendar day standard of promptness applies.
If the 45/90-day SOP date falls on a weekend or holiday, complete the application by the last workday prior to the weekend or holiday.

Application Processing Standards

Observe the following standards in processing ABD applications:

  • Register the application within 24 hours of the agency’s receipt of the application.

  • If the A/R or AREP is not interviewed on the same day an institutional COA application is filed, contact the A/R or AREP within a reasonable timeframe to conduct the required telephone interview.

  • If the A/R or AREP is not interviewed on the same day a non-institutional COA application is filed, and additional information is required, contact the A/R or AREP within a reasonable timeframe.

  • If verification or additional information is required, complete a verification checklist and mail or give to the A/R or AREP. Establish a reasonable deadline for returning requested verification.

  • If the A/R or AREP fails to meet the deadline for providing additional information, attempt to contact the A/R or AREP to assess the need for an extension of the deadline or the possibility of assisting in obtaining required verification.

    Do not deny an application for failure to provide verification if the verification can be obtained by the Case Worker.

  • Contact the nursing home or appropriate case manager by the 30th calendar day from the application date if the LOC instrument has not been received. Document and follow-up as necessary.

  • Deny an application at the first point ineligibility is established. Do not leave a case pending in anticipation of the A/R becoming eligible at a date beyond the ongoing benefit month.

  • Deny the application within two days of SOP if the nursing home or case manager has failed to submit the LOC instrument to the authorized approval source.

    If the LOC approval source has received the LOC instrument but has not yet completed it, do not deny the application.

  • Do not deny an application solely because the 45th/90th/10th day has been reached and eligibility cannot yet be determined.

  • Deny an application before the SOP if the A/R or AREP fails to cooperate in the application process or fails to supply necessary information that s/he is capable of obtaining and DFCS has no direct means of obtaining.

Disposition of the Application

Determine if the A/R meets all points of eligibility.

Process applications in chronological order, when possible, with the exception of Q-Track applications, based on the following:

If eligible, approve the application ongoing and for any retroactive months, if appropriate.

Notification

Provide adequate notification to the A/R of the eligibility determination. A copy may also be sent to a AREP at the request of the A/R. Adequate notification includes the reason(s) for any action taken.

The notice must include the following:

  • the basis for the approval/denial/termination

  • the period of eligibility

  • the reason for the action

  • the A/R’s right to request a fair hearing

  • the telephone number of the county DFCS office

  • the telephone number of legal services

  • the amount of medical expenses required to meet the ABD Medically Needy spenddown, if the A/R meets all eligibility requirements other than income.

  • For LA-D cases in which a penalty is imposed: the duration of the penalty, the Undue Hardship Waiver Form and information that the A/R has 14 days in which to submit the form with supporting info to the MES.

See Section 2342 - Transfer of Assets and Appendix F - TOC for the form.

Period of Eligibility

Approve Medicaid and continue eligibility as long as the A/R continues to meet the requirements of the COA under which they are approved. A CMD must be completed prior to denial or termination of any Medicaid COA. Refer to Section 2052 - Continuing Medicaid Determination.

A COA that has been approved using EMA criteria does not require a CMD when terminated.

Property Search Requirements

Conduct a property search on required ABD Medicaid applicants for the following reasons:

  • to verify the value and status of all real property in which the A/R or deemor declare ownership interest.

  • to detect any undisclosed property in which the A/R or deemor may have ownership interest.

  • to detect and verify any transfer of real property affected by the A/R.

A property search must be completed if a questionable situation regarding ownership of property is discovered during the eligibility determination process.

If necessary, conduct a property search by checking the current tax digest and transfers for the past 60 months in the grantee/grantor book for the county in which the A/R resides or did reside prior to entering LA-D.

Chart 2060.1 – ABD Medicaid Property Search Requirements

If: then a search of the TAX DIGEST is: and a search of the GRANTEE/GRANTOR record is:

the COA is AMN

Not required, unless questionable

Not required, unless questionable

the COA is LA-D (See Chart page 9)

Required

Required

the COA is a Public Law or SSI

Required

Not required, unless questionable

the COA is Q-Track only

Not required, unless questionable

Not required, unless questionable

the A/R has not lived in Georgia during the 24 months prior to the month of application

Not required

Not required, unless questionable

Request assistance in completing a property search from the DFCS office in another county where the client may have resided for a substantial period of time before moving to the current county of residence using Form 991 - MAO Property Search Record. Review the exceptions to property search requirements to determine the necessity for a property search.

Special Considerations

Special Considerations for SSI Applicants

The Social Security Administration (SSA) accepts and processes applications for Supplemental Security Income (SSI) at local SSA offices. Any individual applying for ABD Medicaid at DFCS who appears to be financially eligible for SSI should be referred to the local SSA office to file an application. DFCS will also accept the ABD application for a Medicaid determination and begin the SMEU process. An exception to this may be QMB in some situations.

SSI applicants have the right to have any month for which they have been determined ineligible for an SSI payment for a reason other than failure to meet the disability criteria examined for eligibility under ABD Medicaid. Refer to Section 2053 - Retroactive Medicaid.

DFCS is responsible for determining Medicaid eligibility on SSI applicants in the following circumstances:

  • the three months prior to the month of SSI application for SSI approvals and denials

  • months associated with an SSI application for which the applicant is ineligible for an SSI payment for a reason other than failure to meet disability

  • if an individual is alleging a disability regardless of SSI application status.

An SSI applicant who wants a determination of ABD Medicaid eligibility for months associated with a denied SSI application for reasons other than disability or prior months should contact DFCS to apply for that period of time. The prior months are protected indefinitely until such time as an eligibility determination has been made.

Refer to Section 2053 - Retroactive Medicaid, for processing procedures for retroactive months associated with an SSI application.

Chart 2060.2 - ABD MEDICAL ASSISTANCE FORM REQUIREMENTS

2060.2 chart
Form 216 - Declaration of Citizenship/Immigration status is not required if the A/R has declared their citizenship or immigration status on the eligibility application (94, 94A, 297, 508, 700 or via Gateway Customer Portal application) and signed application under penalty of perjury. Also, declaration of citizenship/immigration status/identity is not required if the A/R is determined under EMA procedures. Refer to Section 2215 - Citizenship/Immigration/Identity.