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QMB Program Manual

B. Application

Updated 9/15/17

1. Application Process Overview

Local offices must use one application process for people applying for multiple APD programs. The process must ensure that application forms are accessible to anyone requesting them and that federal and state eligibility requirements are accurately applied within the applicable time frames.

Local offices are also required to assist clients in completing the application process. This may include helping clients complete the application or gather the information necessary to determine eligibility.

At least one adult requesting assistance must sign the application and complete the application process if able. The applicant or their authorized representative must comply with certain requirements of the application process which are addressed in detail in subsequent portions of this section.

If eligibility cannot be determined during the intake interview, the client must be given or mailed a written notice that outlines the information needed to determine eligibility, the eligibility requirements for the specific QMB program and the amount of time the client will have to provide that information (SDS 0539H). The due date listed on the 539H should be 10 business from the date the pending notice is mailed.  The worker should only allow more than 10 business days if circumstances require more time (e.g. individual must send away for a birth certificate); however, the deadline should allow sufficient time to complete the eligibility determination before the 45th day (unless there is good cause to extend beyond the 45th day). If possible, communicate to the client the importance of returning the information as soon as possible to allow time for processing.  Remember that the deadline can be extended for good cause (see OAR 461-115-0190). Note: If the deadline on the 539H falls on a holiday, use the next working day.

Although clients are not required to have a fixed mailing address, they must provide a location to get notices from the Department. This mailing address cannot be the branch address. To use the branch address means the Department is sending the client notice to the Department and not the client. For the homeless, the mailing address may be General Delivery or the address of a shelter or a friend.

There is a company, Social Service Coordinators (SSC), who may be involved with applications for individuals who are clients of an HMO who has contracted with SSC to do this outreach work. They have approval from the Centers of Medicare and Medicaid Services to undertake this work. SSC’s eligibility workers are centered in Florida and, essentially, are acting as the applicant’s authorized rep. They gather information and verification and send it directly to the local office for processing. Treat these applications in the same manner as any other application. There may be confusion because the client calls and wants to know if the contact is legitimate. The easiest thing to do is ask them if the contact is from SSC or a person from Florida. They may choose to work with the local office instead and that is OK. This outreach does affect people who don’t know about MSPs and can assist them with their Medicare costs.

All signed applications should have a corresponding CMS case. If the individual does not have an open CMS case, create a new one or reopen a closed case (if applicable) and place it in pending status until it's time to approve or deny.


2. Date of Request

The date the client or someone acting on their behalf contacts the Department with a request for benefits is considered the date of request. The contact may be by phone, an office visit or written. Use the date of request to establish the date for starting the application process and the date from which the effective date is determined.


3. Application Requirements

For the branch office to determine eligibility, the applicant or their authorized representative must do all the following:


4. When to Use an Application

A complete application, on a form approved by the Department (SDS 0539A), is required to determine initial eligibility. The application is complete if all the following are true:

A new application is not required under the following circumstances:

Note: This includes current MSP clients who request services; however, staff must provide the client with an Estate Recovery Program brochure (MSC 9093) and an Information of the Transfer of Assets Penalty form (SDS 0543) and narrate.


When to Use an Application: 461-115-0050



5. Who Must Sign the Application and Complete the Application Process

At least one adult requesting assistance or their authorized representative (if there is no adult able to sign the application) must complete the application process and sign the application. If a person who must sign the application is unable to write their name, they may sign with their mark. The mark must be witnessed by an employee of the local office.


6. Authorized Representatives

An authorized representative (AR) may be used to act on behalf of the applicant or filing group to complete the application process, report changes, obtain benefits, or use benefits (for APD, the latter generally applies to SNAP and Special Needs). When possible, the client or spouse should review any information provided by an AR. The filing group is responsible for any information given by their AR; however, the AR is also liable for any QMB, OSIP, or OSIPM overpayment resulting from the AR knowingly giving incorrect or incomplete information or intentionally withholding information.

Important: Simply adding the individual to the 539A and having him/her sign also does not replace the need for an MSC 0231 because there is no information about the AR's potential overpayment liability on the 539A.


7. Offices Where Clients Apply

Applicants must apply at the local office serving the area in which they live. Give applicants who call the wrong office the address and telephone number of the office which would serve them. Applicants who appear for an interview at the wrong office must have their eligibility determined and benefits issued by that office. Immediately afterward, that office will transfer the case to the correct office. Applicants temporarily in another area of the state should apply at the office serving that area.


8. Application Processing Time Frames

Determine eligibility within 45 days from the date of request for benefits. The limit may be extended for any of the following reasons:


9. Application Withdrawal

Clients may withdraw their application at any time during the application process.


10. Interviews

An interview must be conducted to gather information needed to determine eligibility at initial application and at redetermination. The interview is scheduled as promptly as possible to ensure compliance with the application processing time frames; and may be at the local office, out of the office, or by phone. Note: Individuals who are assumed eligible are required to complete an interview at initial application but not at redetermination (see the Redetermination section in APD B.8 and QMB F.4).


11. Verification

Except as provided in the next two paragraphs, verification is required for all eligibility requirements at the initial application, when changes occur and if information is questionable.

Note: Citizenship and identity: Unless exempt, a client declaring U.S. citizenship must provide acceptable documentation of citizenship and identity. An applicant's medical assistance may not be delayed for citizenship documentation while the eligibility decision is pending if all other eligibility requirements have been met (unless previously denied or closed for not providing acceptable documentation)

Verification provided for one program is used as verification for all programs in which the client participates. The Department determines which eligibility factors require verification and what are acceptable types of verification.

See APD WG B.1 for more information on verifying information.

The Department may verify any factors affecting eligibility or benefit levels when they consider them questionable. Information is considered questionable if it is inconsistent with any of the following:

BENDEX automatically sends inquiries to the Social Security Administration for information about the SSB/SSD and Medicare status of all clients with a CMS record. Use the BENDEX systems to verify Medicare eligibility for all clients at initial application and at redetermination. The Department may also decide that additional eligibility factors must be verified.

When acceptable verification is not provided, deny the application or end ongoing benefits.

Verification of the occurrence of an act of domestic violence is not required for any program.


12. Notices

Approval notice. Approval notices are automatically generated when a QMB case is opened or the program-specific case descriptors are coded on CMS. Program notices:

Each notice will include the hearing rights on the second page. Spanish, Russian and Vietnamese versions are also automatically generated.

FS clients receive a notice informing them of FS eligibility and benefit amount when a new or recertification transaction is completed.

Clients will not receive an auto-generated notice related to service eligibility. Notices related to service eligibility need to be sent manually (SDS 541).

Denial or closure notice. Use the SDS 540 and refer to SPD WG G.9 for reason text.

13. Case Documentation

General Rule:  While most eligibility factors can be verified by viewing documents and narrating, it is preferable to make electronic file copies whenever reasonably feasible.

When verifying eligibility factors during a home visit viewing documents is usually acceptable. 

Use the following guidelines when verifying and documenting eligibility factors in the case file:

While all eligibility factors must be narrated (including verifications included in the electronic case file), when physical documentation will not be included in the electronic case file the case narration needs to contain specific information about the eligibility factor being verified.  This information includes but is not limited to:


14. Step-by-Step

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