Library: Policy
317:35-9-25. Application for ICF/MR, HCBW/ID, and persons aged 65 or over in mental health hospitals
Revised 6-25-12
(a) Application procedures for long-term medical care. An application for these types of services consists of the Medical Assistance Application. The Medical Assistance Application is signed by the patient, parent, spouse, guardian or someone else acting on the patient's behalf.
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(1) All conditions of eligibility must be verified and documented in the case record. When current information already available in the local office establishes eligibility, such information may be used by recording source and date of information. If the applicant also wishes to apply for a State Supplemental Payment, either the applicant or his/her guardian must sign the application form. • 1
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(2) At the request of an individual in an ICF/MR or receiving Home and Community Based Waiver Services for the Intellectually Disabled or the community spouse, if application for Medicaid is not being made, an assessment of the resources available to each spouse is made by use of DHS Form MA-11, Assessment of Assets. Documentation of resources must be provided by the individual and/or spouse. This assessment reflects all countable resources of the couple (owned individually or as a couple) and establishes the spousal share to be protected when subsequent determination of Medicaid eligibility is made. A copy of Form MA-11 is provided to each spouse for planning in regard to future eligibility. A copy is retained in the county office in case of subsequent application.
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(3) If assessment by Form MA-11 was not done at the time of entry into the ICF/MR or HCBW/ID services, assessment by use of Form MA-11 must be done at the time of application for Medicaid. The spousal share of resources is determined in either instance for the month of entry into the ICF/MR or HCBW/ID services. If the individual applies for Medicaid at the time of entry into the ICF/MR or HCBW/ID services, Form MA-11 is not appropriate. However, the spousal share must be determined using the resource information provided on the Medicaid application form and computed using DHS Form MA-12, Title XIX Worksheet.
(b) Date of application. When application is made in the county office the date of application is the date the applicant or someone acting on his/her behalf signs the application form. When the application is initiated outside the county office, the date of application is the date the application is stamped into the county office. When a request for Medicaid is first made by an oral request, and the application form is signed later, the date of the oral request is entered in "red" above the date the form is signed. The date of the oral request is the date of application.
1. If individuals are being certified for both Medicaid and a money payment, and have received medical services for a prior period for which they request coverage, the medical services may be processed in the D-section of the computer input form. The Medicaid with the SSP can be certified after the prior service has been processed. If the Medicaid with the SSP has already been certified, use the application for the M-case and process the prior service on the M-case. When the application is completed and signed, the computer input form is prepared and registered on the terminal within five days of the application date.
