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State of Wisconsin |
HISTORY |
The policy on this page is from a previous version of the handbook.
5.3.1.1 Claims Filed on Behalf of Deceased Applicants
5.3.6 Routine SSI-MA Extension
Give a MADA (F-10112) to each person applying for Medicaid Disability. The MADA must be completed by the Medicaid applicant or his or her representative.
The applicant must send the following to the local/county/tribal human or social service agency:
The completed MADA form (F-10112).
Applicants must list information about all of their medical problems and contact information for all medical providers that have treated them,
One copy of the Authorization to Disclose Information to Disability Determination Bureau ( DDB ) (F-14014),
and if applicable
The Medicaid/FoodShare Wisconsin Authorization of Representative form (F-10126).
Even when the applicant is deceased DDB needs medical and other information upon which to base the disability decision. If available, the IM worker should send copies of the following to DDB, along with all other application materials:
Medical reports (if available from the person filing the Medicaid disability application on the decedent’s behalf.)
Death Certificate.
Medical releases (F-14014). If the claim was initiated prior to the applicant’s death and the applicant signed medical releases, those should be sent to DDB. If the applicant was able to sign the releases only with an "X” or other mark, two witness signatures are needed on the release form.
Documentation of guardianship or power of attorney should be included if medical releases are signed by a guardian or person with power of attorney.
The IM worker should complete the MADA form as thoroughly as possible, including:
Name, address, and phone number of next of kin, friend, or other person initiating the Medicaid application on the decedent’s behalf (Section I).
The date on which the applicant became unable to work (Section I, number 2).
Contact information for medical sources treating the applicant prior to and at time of death (Section III).
If Medicaid coverage is needed for less than three full months prior to application the IM worker should include a statement regarding the necessary coverage dates in Part VI of the MADA. For example, when the applicant died shortly after an accident or start of illness and coverage is needed only for brief medical care and/or burial expenses.
See Process Help Chapter 12 Automated Medicaid Disability Determination.
When completed MADA forms are received by the local agency, the IM worker must:
Determine if the applicant meets all other Medicaid eligibility requirements, with the exception of the disability determination and income. Do not send the MADA to DDB if the applicant does not meet all other Medicaid eligibility requirements aside from disability and income, with one exception:
If a non-qualifying immigrant would qualify for Emergency Services Medicaid only if he or she was disabled, send the MADA to DDB.
Ask the applicant to sign a Confidential Information Release Authorization - Release to Disability Determination Bureau form (F-14014). This is the only form DDB can accept. See Process Help Chapter 12 Automated Medicaid Disability Determination.
Leave the box blank that asks for the "Name and Address - Agency/Organization Authorized to Release Information.” DDB has scanners that will automatically fill in the blank. Filling it in creates problems for them.
Applications for disability made by the applicant must include releases that are signed personally by the disabled applicant. Applications made on behalf of a disabled applicant must be accompanied by release forms signed by a legally appointed representative. A copy of the court order appointing a representative must be included with the application. An authorized representative’s signature on the release is not acceptable unless he or she has a court order.
If the applicant has copies of any medical records, school records, etc., include them with the application.
A medical report of disability does not need to be submitted with the application. DDB will obtain all of the medical reports necessary for the disability determination. However, if the applicant or the representative has already provided medical records/reports to the IM agency, this evidence must either scanned into the ECF along with the completed MADA form.
DDB will contact the IM agency for applications that are not fully completed with names and addresses and work information. See Process Help 12.5 How to Resend an Application to DDB.
Occasionally a person applies for SSI and is determined ineligible for SSI payments. In these cases, determine Medicaid eligibility from the SSI application date, if it is earlier than the Medicaid application date.
An application for SSI is also an application for Medicaid.
He or she must still meet all Medicaid eligibility requirements. You must request the SSI application date by using the state on line query (SOLQ).
Use the SSI application date as the filing date if the member contacts the IM agency within the calendar month following the month of the SSI denial. If the contact to the IM agency is later than the above, the filing date is the regular date he or she applied at the IM agency.
An SSI-MA member is eligible for a redetermination of MA eligibility when SSI is terminated. The individual is allowed an extra month of SSI-MA eligibility to allow the member time to have eligibility re-determined by the IM agency. The IM agency must fill the gap in Medicaid eligibility between the last date of SSI-MA and the date an eligibility determination is completed. Determining Medicaid eligibility should usually occur within the month after he or she loses SSI.
When a person applies for SSI and is denied, there is no obligation to "fill gaps.” The exception to this is in Section 5.3.5 SSI Application Date.
There is no fill the gap provision for those who lose their SSI eligibility because of:
The processes differ based on if the member is already open for another program in CARES or if they are not open in CARES.
Active CARES cases- An active case in CARES is one in which the person is part of a case where at least one person is currently open, or closed less than 30 days for at least one program of assistance. If the member has an active case in CARES, the fiscal agent sends a list to the agency’s CARES coordinator of those losing SSI and sends those members a letter saying the IM worker will contact them if there is not enough information to determine eligibility.
As soon as the IM worker receives the list of those in active CARES cases, he or she:
Opens the member for Medicaid in CARES. This may seem unusual since he or she will show eligibility on MMIS for a grace month. The reason you open all of them in CARES is to provide a tracking mechanism to show you "filled the gap” and that the member receives the correct notice, if he or she fails eligibility later. CARES instructions are:
Case Information> Request Medicaid page- Request Medicaid
Benefits and School> Benefits Received page- Change the Y in the SSI field to N or on the Benefits Received page - change the Y in the 1619(b) field to N.
Don’ t change any financial information (unless you need to in order to make the person eligible). Complete any other required demographic information.
Verifications aren’t required at this point.
Run eligibility and confirm.
The day after you open the case, request verification of any items you need to determine continued Medicaid eligibility. At this point, treat the case as a regular case, and all verification rules, etc. apply. The member has 10 days to provide verifications.
Non CARES- If the member does not have an active case on CARES, the fiscal agent sends a letter along with an application telling him or her that he or she must apply. The member sends the application to the fiscal agent and the fiscal agent forwards it to the CARES coordinator, who assigns it to a worker. The worker enters the case and determines eligibility. MMIS will close those cases that do not send an application within 30 days of their request.
Reminder: For all cases (CARES and non-CARES), even if the member does not meet Medicaid eligibility requirements for the months between when he or she lost SSI and when you are re-determining eligibility, he or she is still eligible. Do not require the member to come into the office. Ineligibility starts, following timely notice, when he or she:
Does not return the application (the fiscal agent takes care of this, or
Fails to respond to an information request, or
No longer meets eligibility requirements (only forward from when the review or application is done).
Fill the gap between the loss of SSI-MA and an eligibility determination by the IM agency when:
Retroactive SSI approval and termination occurs. A person applies for SSI and is approved. The approval is retroactive and the SSI also is terminated retroactively.
Eligibility for Medicaid is not determined timely by the IM agency through no fault of the member.
This page last updated in Release Number: 15-01
Release Date: 06/10/2015
Effective Date: 06/10/2015
The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.
Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.
Publication Number: P-10030