Eligibility Online Manual

M403 Processing Applications For Medical Benefits

Purpose: This section will assist in processing applications for medical benefits.


Current Policy Effective Date: September 1, 2018

Date Last Reviewed: July 9, 2018

Previous Policy: August 1, 2016

POL M403: PROCESSING APPLICATIONS FOR MEDICAL BENEFITS

1. Application For Medical Benefits

Applicants must complete an application for medical benefits. Refer to Section M401 for a list of applications.

Applications may be submitted online, emailed, faxed, mailed, or delivered to the Wyoming Department of Health Customer Service Center or the Medicaid Long Term Care Unit, depending upon the type of case.

2. Applications Must Be Date Stamped

Applications must be date stamped when received. For applications received after hours, on a weekend or holiday, the date stamp would be the first working day after receipt.

3. Applications Must Be Signed

Applicants who submit an application without a signature must sign within 45 days of receipt. The application must be registered, and the applicant must be notified of this requirement. Eligibility cannot be determined until the application is signed.

4. Applications Must Be Complete

Applicants who submit an application that is not complete must provide the information necessary to determine eligibility within 45 days of receipt. The application must be registered and the applicant must be notified of this requirement.

5. Interviews Must Be Conducted Within 45 Days

Interviews must be conducted within 45 days from the date of application for the Long Term Care programs. Interviews may be conducted by telephone or in person in the Cheyenne office.

Interviews are not required for the Family and Children’s, Medicare Savings, Employed Individuals with Disabilities, Breast and Cervical Cancer, and Tuberculosis programs.

6. Applications Must Be Approved Or Denied Within 45 - 90 Days

Applications must be approved or denied within 45 days from the date of application unless waiting for third party verification. In this case, the decision must be made within 60 days.

The only exception is when a disability determination is pending. In this case, a decision must be made within 90 days.

7. Applicants Who Declare U.S. Citizenship Have 90 Days To Provide Verification

Applicants who declare U.S. Citizenship have up to 90 days to provide verification when verification cannot be obtained by the Wyoming Department of Health Customer Service Center or the Medicaid Long Term Care unit, depending upon the case.

Benefits must be authorized for applicants, who meet all other eligibility requirements, while verification of citizenship is being obtained.

Benefits must close when verification is not provided within 90 days.

Only one reasonable opportunity period can be authorized per client.

8. Benefits Must Not Be Postponed

Benefits must not be postponed due to delays in other program eligibility determinations/requirements.

9. Agency Receives Information Or Verification After Denial Or Closure Of Application

A new application is required when information or verification is received more than 60 days from denial and 90 days from closure.

10. Refer Children With Special Needs To Children’s Special Health Services

Notify the WDH Children’s Special Health Services (CSH) program when an application indicates that a child has a diagnosed medical condition. FAX a copy of the application to CSH at 307-777-7215.

11. Furnish WHIPP Application To Applicants/Clients Who Have Insurance

12. Furnish Estate Recovery Brochure To Applicants

Applicants who are age 55 or older or applicants who are an inpatient in a medical institution may be subjected to Estate Recovery. An applicant must be informed of this requirement by providing the Estate Recovery Brochure. For questions concerning estate recovery contact 307-777-5389.

Medicare Savings programs are not subject to Estate Recovery.

Reference:

Defining Requirement: 42 CFR 435.905 – 912

Clarifying Information:

Worker Responsibilities:

Evaluating Applications For WHIPP Participation

1. Refer to Section M411 for information on determining WHIPP participation.