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Effective: December 1, 2006 |
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07.05.05ar1 - Application Forms (Archive) |
Archived: January 1, 2007 |
There are several application forms which can be used to apply for health care depending on the client's situation and the program he or she is applying for. The applications gather eligibility information about the client.
General Application Form Requirements.
Health Care Application (HCAPP).
Combined Application Form (CAF).
MA-BC Application/Renewal Form.
Required Questions for Long-Term Care (LTC).
Request for Payment of LTC Services.
General Application Form Requirements
Accept any of the DHS approved signed and dated application forms as detailed in this section.
l Do not require a specific application, when another meets the conditions for use.
l Do not require forms or verifications not prescribed by DHS as a condition of eligibility regardless of what application form is used.
Example:
County A has developed a form that includes specific information about the agency’s hours of operation, other resources available in the county, instructions on how and when to reach the worker to report changes, etc. The form also includes some of the client rights and responsibilities that are incorporated on the application form.
Action:
County A may send this form to applicants at the time of approval. Do not include the form with the HCAPP or require the applicant to sign and return it.
Health Care Application (HCAPP)
The HCAPP (DHS-3417) allows people to apply for any or all of the Minnesota Health Care Programs (MHCP) on one form. Questions on the HCAPP may apply to all health care programs, only to one or two programs, or to specific populations.
The HCAPP has several functions:
l Collect eligibility information.
l Provide the client with their rights and responsibilities. Clients should detach these pages and retain them for their records.
Note: Clients applying for payment of LTC services with a version of the HCAPP prior to September 2006, must also complete the Required Questions for Long-Term Care (DHS-4803) for eligibility to be determined.
Advise clients that the Minnesota Health Care Programs Application (HCAPP) is also available on the DHS web site at www.dhs.state.mn.us/healthcare.
Combined Application Form (CAF)
The following clients should use the CAF (DHS-3469) to apply:
l Clients applying for cash and Food Support (FS), or other emergency programs, with or without MHCP, must use the CAF.
n An interview is required for cash and FS.
n If the client fails to attend the interview or uses the CAF to request health care only, do not require an interview as a condition of eligibility.
l Clients who are uncertain what programs they are applying for.
Note: Clients applying for payment of LTC services with a version of the HCAPP prior to September 2006, must also complete the Required Questions for Long-Term Care (DHS-4803) for eligibility to be determined.
The MN MA Breast and Cervical Cancer Coverage Group (MA-BC) Application/Renewal (DHS-3525) is used for women who are screened and found to need treatment through the Sage Screening Program.
The Required Questions for Long-Term Care (DHS-4803) must be sent to applicants who apply using a CAF or a version of the HCAPP prior to September 2006. The form is required for eligibility of payment of LTC services because the questions are not found on these applications.
Request for Payment of LTC Services
The Request for Payment of LTC Services (DHS-3543) is sent to enrollees who are requesting payment of Long Term Care services due to either a placement in a Long Term Care Facility (LTCF) or has begun receiving home care services through any of the home and community-based waiver programs (CADI, CAC, MR/RC, TB and EW).
Note: Eligibility for payment of LTC services cannot be determined until a request for payment has been received. The request can be the DHS-3543, the HCAPP or another acceptable application form.
For children applying for Title IV-E Foster Care, a HCAPP and a Title IV-E Foster Care Supplement to Health Care Programs (DHS-3478) is used to determine eligibility for the IV-E program.
l If the child is IV-E eligible, MA is automatic.
l If the child is not IV-E eligible, the HCAPP is used to determine the MA or MCRE eligibility.
GAMC applicants must complete the Required Questions for General Assistance Medical Care (DHS-3423) in addition to an application.
Applicants and enrollees may need to complete additional forms to complete the application process. Additional forms are based on eligible programs and household conditions.
Other forms may include:
l Health Insurance Information Form (HIIF) (DHS-1922b).
n The information gathered on this form is also included as questions on the HCAPP.
n Do not require the HIIF if the applicant supplies the information on the HCAPP or by other means, such as providing the information by phone or submitting copies of insurance cards.
l Medical support referral forms. These include:
n Important Information on Child and Medical Support Services (DHS-3163C).
n Medical Support Referral Form (DHS-3163B).
n Good Cause Form (DHS-2338).
l Medical Services Questionnaire (MSQ) (DHS-2237).
n Agencies may use MSQs to gather information about current or pending Third Party Liability (TPL).
n Do not submit the MSQ to Benefit Recovery Section (BRS). Record the information on the MAXIS ACCI screen.
l Managed care enrollment information.
n Managed care forms are used for eligible applicants who are required or volunteer to enroll in managed care.
n See Managed Care for a list of items to include in managed care education and enrollment packets.