IMA POLICY MANUAL
PART VII: SPECIAL MA PROCESSING
CHAPTER 4: DC HEALTHCARE ALLIANCE PROGRAM
PROCESSING APPLICATIONS 4.5
Applications for the Alliance program may be submitted by mail, facsimile, or in person at any IMA service center. Applicants should use the Combined Application that is used to apply for multiple programs. Applicants may also submit their applications to an out-stationed IMA employee working in a community setting. Every applicant has the right to file an application on the same day that s/he contacts IMA. An application is considered to be filed when the signed and dated application form is received by the IMA representative.
Except as otherwise stated below, applications for the Alliance program are processed in accordance with policies established for AR Medicaid in Part III: Chapter 1, Application Processing: Filing an Application.
Who May File the Application 4.5.1
Any individual or either spouse of a married couple may file the application for Alliance benefits. The applicant may designate an authorized representative to act on his/her behalf. See Part III: Chapter 1, Application Processing: Filing an Application, for additional information on designating an authorized representative. An applicant has the right to refuse to name an authorized representative.
Application Review 4.5.2
Effective September 27, 2011, a face-to-face interview with the applicant is required to complete applications for Alliance benefits. During the face-to-face interview, the SSR shall:
:
- Inform the applicant of his/her rights and responsibilities
- Explain the program and related services
- Outline the conditions of eligibility and indicate what verification and information are necessary to determine eligibility
- Notify the applicant that information s/he provides will be matched by computer with information from other local, state and federal agencies
- Explore and resolve any unclear or incomplete information.
Request for Waiver of Face-to-Face Interview 4.5.2a
Applicants may request a waiver of the face-to-face interview requirement on the basis of being unavailable during the application period due to hospitalization, disability, or being aged 65 or older. Applicants (or their authorized representatives) must submit the following supporting documentation to be considered for a waiver:
- For persons who are hospitalized, written documentation from a hospital or other medical professionals on the hospital or provider letterhead, attesting that the applicant is not available for an interview due to disability or illness, including a diagnosis and prognosis, and that the applicant will not be available for the 45-day period beginning with the date of application. These waiver requests will be reviewed by the Medical Review Team.
- For persons who are age 65 or older, a written statement from the applicant explaining why they cannot participate in the face-to-face interview during the 45-day period beginning with the date of application. Waiver requests from persons who are elderly will be reviewed by the Agency on a case-by-case basis.
Application Timeframes 4.5.3
Applications for the Alliance program must be processed within 45 days, counting from the day after the application was filed. A verification checklist, listing all information or actions still needed to determine eligibility must be issued through ACEDS and given to the applicant at the time the application is filed. The checklist and the date the application was filed are essential for the timely issuance of all application notices and timely disposition of the application.
If an applicant fails to provide all necessary verification by the tenth day following the application date, ACEDS will issue a Ten-Day Notice that lists the information or actions needed to complete the eligibility determination. If the applicant still has not provided all necessary verifications by the 30th day following the application date, ACEDS will issue a 30-Day notice that also reports what is needed to complete the eligibility determination.
If by the 15th day following the 30-day notice (or the next available workday), the applicant has not provided all verifications, ACEDS will issue a denial notice and deny the application.
It is IMA's goal to complete the eligibility determination within 10 days from the date that all information necessary to determine eligibility has been submitted.
Expedited Determinations 4.5.4
IMA shall conduct expedited determinations (on the same or next business day) for any applicant who has an urgent medical need that is certified by a clinician. Applicants may request an expedited determination from the IMA Office of the Administrator by telephone, fax, or in person. A need for an expedited determination does not relieve an applicant from the requirement to participate in a face-to-face interview, unless waived (see Section 4.5.2a: Request for Waiver of Face-to-Face Interview in this Part.)
Application Approvals 4.5.5
If all financial and nonfinancial conditions of eligibility are met, the SSR will approve benefits.
Period of Eligibility 4.5.6
Eligibility shall begin on the first day of the month of application. Effective September 27, 2011, applicants shall be certified for six (6) months.
Applicants are not eligible for coverage for any month prior to the month of application.
Application Denials 4.5.7
The application for Alliance benefits will be denied if:
- The applicant does not cooperate with IMA in providing the information needed to determine eligibility
- Conditions of nonfinancial eligibility have not been met
- Income and/or assets exceed established limits
- The application has been voluntarily withdrawn or abandoned
- The applicant establishes eligibility for federally-funded Medicaid.
- The applicant fails to complete a face-to-face interview, unless a waiver has been granted in accordance with Section 4.5.2: Application Review in this Chapter.
The applicant must be notified of the denial, the reason for the denial, and his/her right to a fair hearing.
Terminations due to Non-Compliance with New Requirements 4.5.7a
Effective September 27, 2011, persons who were determined eligible for the Alliance under prior rules may be required to comply with rules effective September 27, 2011. The Agency shall give at least thirty days' notice of the new requirements. Persons who do not comply with the new requirements may be terminated after timely and adequate notice.
Notices 4.5.8
A notice indicating a decision to deny an application for the Alliance benefits must be issued by the 45th day after the date of application, or in the case of an automated denial for abandonment or failure to return verifications, by the 15th day after a 30-Day notice was sent (or the next available work day). If the applicant is denied benefits, the notice must include the reason for the denial and provide information on the applicant's right to a fair hearing. If the application is approved, the notice must be issued by the 45th day from the date of application, or within 10 days of establishing eligibility, if eligibility is established after the 35th day from the date of application. An approval notice should indicate the effective date of the approval, and notify the applicant of his/her right to request a fair hearing.
