Medical Assistance for Women with Breast or Cervical Cancer

2.5.1.1.1 Applications (Archive)

Women, who are screened through the Minnesota Department of Health (MDH) Sage Screening Program and are found to need treatment or diagnostic services for breast or cervical cancer, are potentially eligible for Medical Assistance for women with Breast or Cervical Cancer (MA-BC).

Application Paths

A woman must apply for MA-BC. There are two paths to requesting an MA-BC eligibility determination.

1. A temporary eligibility determination, referred to as presumptive eligibility (PE), may be granted by a Minnesota Health Care Programs (MHCP) provider participating in the Sage Screening Program.

2. Some women do not have presumptive eligibility determined and directly apply for MA-BC using the Minnesota MA Application/Renewal Breast and Cervical Cancer (DHS-3525) form.

Forms

Temporary Medical Assistance Authorization (DHS-3525B)

The Temporary Medical Assistance Authorization (DHS-3525B) is completed by the provider and authorizes presumptive eligibility.

Minnesota MA Application/Renewal Breast and Cervical Cancer (DHS-3525)

The Minnesota MA Application/Renewal Breast and Cervical Cancer (DHS-3525) form is for women who were screened by the Sage Screening Program, need treatment or diagnostic services for breast or cervical cancer and are seeking MA-BC coverage. Enrollees also use this form to renew eligibility for coverage.

Application Filer

The applicant or an authorized representative is the application filer. Only a person meeting the definition of an application filer or an authorized representative can sign the application or renewal. See the MHCP Authorized Representative policy for more information.

Date of Application

The date of application is the date the county, tribal or state servicing agency receives DHS-3525.

Presumptive Eligibility

PE provides immediate MA-BC coverage for women who need to begin treatment. PE is granted to women who meet the MA-BC presumptive eligibility criteria. Presumptive eligibility is effective on the first day of the month PE is granted and continues through the end of the month following the month it was granted.

The PE provider must complete and submit to the county, tribal or state servicing agency:

• MDH Sage Enrollment form, Sage Return Visit form, or Colposcopy Program form

• Copy of Temporary Medical Assistance Authorization (DHS-3525B)

The county, tribal or state servicing agency must process DHS-3525B the day the form is submitted.

A woman granted PE must complete the Minnesota MA Application/Renewal Breast and Cervical Cancer (DHS-3525) form to have an ongoing eligibility determination. The DHS-3525 must be submitted to the county, tribal or state servicing agency within 30 days of the date presumptive eligibility is granted. The county, tribal or state servicing agency must process the application for ongoing MA-BC within 45 days. An applicant may complete and submit the DHS-3525 on the same date PE is granted.

If a person granted PE does not submit an application for on-going MA-BC coverage or is not eligible for MA-BC, PE ends the last day of the month following the month PE was granted.

A woman granted PE who is denied ongoing MA-BC eligibility is entitled to receive coverage for the full PE period.

Retroactive Coverage

A woman may request retroactive coverage. The earliest date of eligibility is three months before the date of application or the first day of the month in which the woman was screened by Sage, whichever is later. The woman must have paid or unpaid medical expenses during the retroactive period that would be covered by MA. Women who are granted presumptive eligibility for MA-BC must be found eligible for ongoing MA-BC before retroactive eligibility is granted.

Legal Citations

Code of Federal Regulations, title 42, section 1383

Code of Federal Regulations, title 42, section 1396a(aa)

Code of Federal Regulations, title 42, section 1396r–1b

Code of Federal Regulations, title 42, section 1920B(b)(1)

Public Law 106-354 October 24, 2000

Published:  June 1, 2016

Archived: January 1, 2019