Policy History for  3.6.2 Application Process

Release 07-08

3.6.2 Application Process

3.6.2.1 Application Form

Give a Medicaid - Disability Application (MADA) form ( HCF 10112 ) to each person applying for MA Disability.  The MADA form must be completed by the Medicaid applicant or his/her representative.  

The applicant must send the following to the local/county/tribal human or social service agency.
 

  1. The completed MADA form (HCF 10112).

    Applicants must list information about all of his/her medical problems and contact information for all medical providers that have treated him/her.
     

  2. Two signed copies of the Authorization to Disclose Information to Disability Determination Bureau (HCF 14014).  

    and if applicable
     

  3. The Medicaid/FoodShare Wisconsin Authorization of Representative form (HCF10126).
     
     

3.6.2.1.1 Claims filed on behalf of Deceased Applicants

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: 

  1. Medical reports ( if available from the person filing the MA disability application on the decedent’s behalf.)

  2. Death Certificate.

  3. Medical releases (Form HCF 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.

  4. 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:
 

  1. Name, address, and phone number of next of kin, friend, or other person initiating the MA application on the decedent’s behalf (Section I).

  2. The date on which the applicant became unable to work (Section I, number 2).

  3. Contact information for medical sources treating the applicant prior to and at time of death (Section III).
     

If MA 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.  

3.6.2.2 Agency Form Processing

When completed MADA forms are received by the local agency, the IM worker must:

  1. Determine if the applicant meets all other Medicaid eligibility requirements, with the exception of the disability determination and income.  There is a reminder for the IM worker in Section IX of the MADA application that it (the application) should not be sent to DDB if the applicant does not meet all other Medicaid eligibility requirements aside from disability and income.
     

Note: Pend the case in CARES while you are waiting for a disability decision from DDB enter a "?" in the disability verification field on the disability page in CWW.  Extend the date on AGVC and send a manual notice within 30 days of the filing date, telling the client that eligibility is pending the disability decision.  Remind him/her to report any changes within 10 days. If there are other program requests, the case must be in ongoing" mode before entering the ? on the disability page to pend the Medicaid.

  1. Complete and sign Section IX of the MADA form.

    Note    :  DDB will return MADA forms which do not have an IM workers signature in Section IX.  If the identity of the IM worker is unknown DDB will send the incomplete form to an IM supervisor in the appropriate county/tribal agency.  

    Section IX is a checklist for the IM worker.  In Section IX, the Income Maintenance (IM) worker confirms:
     

    1. The MADA is complete

      At a minimum, the following sections must be complete:
       

    2. The applicant meets all other Medicaid eligibility criteria except for a disability determination and income..
       

    3. The MADA includes two properly signed Authorization to Disclose Information to Disability Determination Bureau forms (HCF 14014).  If the applicant has appointed someone to represent him/her, a properly completed and signed Medicaid/FoodShare Wisconsin Authorization or Representative form (HCF 10126).
       

  2. Mail the completed forms to:
     

Regular Mail

Disability Determination Bureau

P.O. Box 7886

Madison, WI 53707-7886

 

Certified Mail

Disability Determination Bureau

722 Williamson Street

Madison, WI 53703

3.6.2.3 Release Form

Ask the applicant to sign a Confidential Information Release Authorization – Release to Disability Determination Bureau form (HCF 14014) for each medical source identified on the application form plus several additional copies.  (Some hospitals and institutions require a release for each department.)  This is the only form DDB can accept.

 

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 s/he has a court order.  

3.6.2.4 Medical Report

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 be sent to DDB along with the completed Medicaid disability application (MADA) form or the evidence should be scanned into your electronic case file (ECF).  Notify DDB that the medical record/reports information is in ECF by making a notation at the bottom of section IX on the MADA.

 

Applications that are not fully completed with names and addresses and work information will be returned to the local IM Agency.

3.6.2.5 SSI Application Date

Occasionally a person applies for SSI and is determined ineligible for SSI payments.  In these cases, determine MA eligibility from the SSI application date, if it is earlier than the Medicaid application date.

An application for SSI is also an application for MA.  

S/he must still meet all MA 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 client 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 s/he applied at the IM agency .  

3.6.2.6 Routine SSI-MA Extension

The IM agency  fills the gap in eligibility between the loss of SSI-MA and an eligibility determination by the IM Agency.  Certify the client for the period between the loss of SSI-MA eligibility that appears on MMIS and when you will be able to determine their MA eligibility.  Determining MA eligibility should usually occur within the month after s/he loses SSI.

When a person applies for SSI and is denied, there is no obligation to “fill gaps.”  The exception to this is in 3.6.2.5.

The IM agency  will fill the gap in eligibility when an ongoing SSI case is terminated.  The person is eligible for a re-determination of MA eligibility by the IM agency .  S/he should apply within the calendar month of notification of termination.  An extra month of SSI-MA eligibility is posted on MMIS to allow the client time to have eligibility determined by the IM agency .  

There is no fill the gap provision for those who lose their SSI eligibility because of:
 

  1. Death

  2. Leaving Wisconsin

  3. Incarceration

  4. Fleeing drug felon
     

3.6.2.6.1 Case Processing

The processes differ based on if the client is already open for another program in CARES Client Assistance for Re-employment & Economic Support or if they aren’t open in CARES. The starting point for both CARES and non-CARES cases is an MMIS and SOLQ query.

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 client has an active case in CARES, EDS sends a list to the agency’s CARES coordinator of those losing SSI and sends those clients a letter saying the IM worker will contact them if there isn’t enough information to determine eligibility.  

As soon as the IM worker receives the list of those in active CARES cases, s/he:

  1. Opens the client for MA in CARES.  This may seem unusual since s/he 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 client receives the correct notice, if s/he fails eligibility later.  CARES instructions are:
     

    1. ACPA- Request MA

    2. ANBR- Change the Y in the SSI field to N or on ANBC – change the Y in the 1619(b) field to N.

    3. Don’t change any financial information (unless you need to in order to make the person eligible).

    4. Complete any other required demographic information.

    5. Verifications aren’t required at this point.

    6. Run eligibility and confirm.  

 

  1. The day after you open the case, request verification of any items you need to determine continued MA eligibility.  At this point, treat the case as a regular case, and all verification rules, etc. apply.  The client has 10 days to provide verifications.

 

Non CARES- If the client doesn’t have an active case on CARES, EDS sends a letter along with an application telling him/her that s/he must apply.  The client sends the application to EDS and EDS 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.
 

  1. Reminder:  For all cases, (CARES and Non-CARES) even if the client doesn’t meet MA eligibility requirements for the months between when s/he lost SSI and when you are re-determining eligibility, s/he is still eligible. Don’t require the client to come into the office.  Ineligibility starts, following timely notice, when s/he:

 

    1. Does not return the application ( EDS takes care of this, or

    2. Fails to respond to an information request, or

    3. No longer meets eligibility requirements (only forward from when the review or application is done).

3.6.2.7 Other SSI-MA Extensions

Fill the gap between the loss of SSI-MA and an eligibility determination by the IM agency when:

 

  1. 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.
     

  2. Eligibility for MA is not determined timely by the IM agency through no fault of the client.

 

 

This page last updated in Release Number: 07-05

Release Date: 07/10/07

Effective Date: 07/10/07