Applicants and Application Forms

Applicants and Application Forms A. An applicant is defined as someone: 1. Whose signed application form has been received by the Division of Medicaid and is requesting an eligibility determination, 2. Whose signed application has been received by another agency or entity authorized to make Medicaid certifications, or 3. Who applies for coverage in Mississippi through the Federally Facilitated Marketplace (FFM) and has their electronic application information transferred to the Division of Medicaid via a process referred to as an Account Transfer (AT). B. An application for Medicaid on behalf of a deceased individual must be filed before the end of the third (3rd) month following the date of death in order for the Division of Medicaid to be able to consider the month of death for coverage using the rules that apply for retroactive Medicaid. C. A non-applicant is defined as an individual who is not requesting an eligibility decision for himself or herself but is included in the applicant’s household to determine eligibility for the applicant. D. The Division of Medicaid uses three (3) types of application forms to determine eligibility: 1. For modified adjusted gross income (MAGI) related purposes, the Mississippi Application for Health Benefits is the single streamlined application form used to apply for Medicaid and the Children’s Health Insurance Program (CHIP). Information from this form is also used to refer individuals to the FFM for health coverage if ineligible for health coverage through the Division of Medicaid. 2. For aged, blind and disabled (ABD) purposes, the Application for Mississippi Medicaid Aged, Blind and Disabled Medicaid Programs is used. 3. For Family Planning purposes, the Application for Family Planning is the streamlined application form used to apply specifically for the Family Planning waiver program coverage. E. The (MAGI) related, ABD, and family planning application forms may be a paper version, an electronic version or an exact facsimile of the appropriate form. F. Applications filed for Medicaid coverage through other agencies or entities have their own Medicaid applications, such as Social Security Income (SSI), Child Protection Services (CPS), hospital presumptive eligibility (HPE), and presumptive eligibility for pregnant women (PEPW). G. The application form is a legal document completed by the applicant or representative that signifies intent to apply and is: 1. The official agency document used to collect information necessary to determine Medicaid eligibility, 2. The applicant’s formal declaration of financial and other circumstances at the time of application, 3. The applicant’s certification that all information provided is true and correct, signed under penalty of perjury, regardless of whether the application is completed and submitted electronically, by telephone or in paper form. 4. Providing notice to the applicant of his rights and responsibilities, and 5. May be introduced as evidence in a court of law.