Who can file
An application must be provided to anyone upon request and may be requested in person, by mail, telephone, facsimile, secure e-mail, or at any designated agency. ABD Manual 2050-1. Anyone may apply for Medicaid benefits, including the following:
- The individual requesting assistance;
- A personal representative (PR) acting on behalf of the applicant. The PR can be a relative, friend, guardian or any person in a position to know the applicant’s circumstances;
- The parent, specified relative or individual who provides/provided care and control of a child or deceased individual;
- An individual acting on behalf of an AU, including a representative of a private law firm or cost recovery company;
- A child requesting assistance for himself/herself;
- A Medicaid provider, for a newborn via DMA Form 550, Newborn Eligibility Certification Form or via the web portal (ABD Manual § 2050-2)
See also ABD Manual Section 2050-2, stating who may apply. The form of the application is governed by 42 C.F.R. § 435.907.
A Community Spouse is entitled to file a Medicaid application to avail himself or herself of the protection afforded in 42 U.S.C. § 1396r-5. Subsection (c) gives the community spouse the right to a resource assessment. The remainder of Section 1396r-5 describes the community spouse’s income and resource rights. Subsection (e) gives the community spouse appeal rights.
Choice of Category
The agency must allow an individual who would be eligible under more than one category to have his eligibility determined for the category he selects. 42 C.F.R. 435.404. In Georgia, eligibility for Medical Assistance must be determined under all COAs before an application is denied. ABD Manual Section 2050-4.
Opportunity; assistance
Federal law requires States to provide all individuals wishing to make application for medical assistance with the opportunity to do so and requires that assistance be furnished with reasonable promptness to all eligible individuals. 42 U.S.C. § 1396a(a)(8). The opportunity to apply must be provided without delay. 42 C.F.R. § 435.906.
Specifically 42 U.S.C. § 1396a(a)(8) provides: A State plan for medical assistance must — provide that all individuals wishing to make application for medical assistance under the plan shall have opportunity to do so, and that such assistance shall be furnished with reasonable promptness to all eligible individuals. Georgia’s manual instructs caseworkers to assist as needed to complete the application. 2050-3. Again, at ABD Manual Section 2051-5, [t]he agency is responsible for assisting applicants/recipients in obtaining verification when the applicant/recipient requests assistance (refer to Section 2020, ADA Regulations).
Notice of Rights
A Medicaid applicant must be informed of certain rights at the time of application, which include: (1) the right to a hearing; (2) the method by which he may obtain a hearing; and (3) that he may represent himself or use legal counsel, a relative, a friend, or other spokesman. 42 C.F.R. § 431.206(b) and (c). There is, however, nothing in the statute or regulations requiring a Court, such as an administrative law court, to permit a non-lawyer to represent an applicant at a hearing. In fact, Rule 616-1-2-.34(1) prohibits a non-attorney from representing someone else in court. In Weeks v. DHS, the ALJ noted that the authority to file a Medicaid application is broader than the authority to appeal the denial of an application. The nursing home had no written authorization to act for the resident and had no Order appointing it as her guardian.
Notices must be in simple and understandable terms. 42 C.F.R. § 435.905(b).
Notice of these rights must also be provided at the time of any action affecting his or her claim; at the time a skilled nursing facility notifies a resident of a proposed transfer or discharge; and at the time an individual receives an adverse determination regarding a preadmission screening or annual review. 42 C.F.R. § 431.206(c)(2) through § 431.206(c)(4). Notices must be in simple and understandable terms. 42 C.F.R. § 435.905(b). At 77 F.R. 17208 (March 23, 2012), § 435.905 was revised to provide that information regarding rights and responsibilities must be provided in plain language that is accessible and timely, including to individuals with limited proficiency in English and to individuals with disabilities.
