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 as determined by a Sage PE provider.

Once a Sage PE provider has granted PE, no additional eligibility criteria may be applied. A woman approved for PE cannot be required to attest to or provide more information about her state residency,citizenship or immigration status, household composition, income or other factors. All eligibility factors  relevant to PE have been considered by the Sage PE provider when PE is approved.

Temporary MA-BC eligibility is effective on the first day of the month PE is approved by a Sage PE provider and continues through the end of the month following the month it was approved.

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

• MDH Sage Enrollment form

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

The county, tribal or state servicing agency must enter MA-BC eligibility in MAXIS and MMIS per the DHS-3525B the day the form is submitted. MA-BC must be opened for a woman approved for PE by a Sage PE provider, in accordance with the date of the Temporary Medical Assistance Authorization, regardless of other health care applications that are pending.

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

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

Ongoing Eligibility for MA-BC

To have an ongoing eligibility determination for MA-BC, a woman approved for PE must complete the Minnesota MA Application/Renewal Breast and Cervical Cancer (DHS-3525) form. The DHS-3525 must be submitted to the county, tribal or state servicing agency within 30 days of the date the presumptive eligibility is approved by a Sage PE provider. 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 approved.

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 1100-1103

Code of Federal Regulations, title 42, section 435.213

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

Public Law 106-354 October 24, 2000

Public Law 107-121 January 15, 2002

Published:January 1, 2019

Archived: December 1, 2020