109 APPLICATION PROCESS SR 13-06, 10/13 (MAM-A)

To complete the application process, the applicant must do all of the following:

• complete an application:

• participate in an eligibility interview if required by the program of assistance requested; and

• provide all required verification within timeframes.

Individuals have the right to:

• apply for assistance;

• file an application on the same day the District Office has been contacted; and

• have an eligibility decision made on their application for assistance.

Individuals can apply for assistance in 4 ways:

• Individuals can apply for assistance by visiting the following website and completing an application online: www.nheasy.nh.gov or, for Medical Assistance only, www.HealthCare.gov;

• Individuals can print an application from http://www.dhhs.nh.gov/dfa/apply.htm or http://www.dhhs.nh.gov/dfa/forms.htm and mail or fax the completed application to the District Office;

• Individuals can apply over the phone by calling 1-800-852-3345, extension 9700; or

• Individuals can contact a District Office and request an application per the instructions below.

Requesting an Application from a District Office

An individual may request an application by contacting any District Office.

• DFA Form 800, Application for Assistance, is provided to anyone requesting an application.

If the individual contacts the District Office by telephone, fax, or mail, direct the individual to the NH EASY website so that the individual can immediately complete the online application, or notify the individual of the availability of the application on the Department’s website, where the DFA Form 800 can be printed off immediately for the individual’s use. If the individual does not have access to a computer or the Internet, mail DFA Form 800 to the individual on the same day the request is received.

• DFA Form 800P, Application for Children’s Medicaid (CM) and Medical Coverage for Pregnant Women (MCPW), can be provided to clients who only want to apply for:

- MCPW: Medical Coverage for Pregnant Women; or

- CM: Children’s Medicaid, for children aged 0-19 with family income no higher than 300% of federal poverty income guidelines.

Households may also apply for MCPW, and CM at participating local health facilities, contract agency clinics funded by the Department of Public Health Services, and other authorized agencies or organizations. No face-to-face interview is required. Authorized providers will furnish and accept DFA Form 800P on site.

Prior to giving or mailing DFA Form 800P to the applicant, advise the individual of the availability of other DFA programs. If the individual chooses to use DFA Form 800P, offer the opportunity for a personal interview and provide the applicant with a clear explanation of the application process and verification requirements associated with DFA Form 800P.

DFA Form 800P is used to apply for MCPW, and CM only. If the client wishes to apply for additional programs of assistance, DFA Form 800 must be completed and a face-to-face interview or attendance at the NHEP orientation may be required.

• DFA Form 800MA, Application for Health Coverage & Help Paying Costs, is provided to clients who only want to apply for MAGI-related Medicaid programs and other ACA related health coverage options that become effective January 1, 2014.

Households may also apply for MAGI-related Medicaid programs and other ACA related health coverage options that become effective January 1, 2014 by going to https://nheasy.nh.gov/ or www.HealthCare.gov and completing an application online. No interview is required.

Prior to giving or mailing DFA Form 800MA to the applicant, advise the individual of the availability of other DFA programs. If the individual chooses to use DFA Form 800MA, offer the opportunity for a personal interview and provide the applicant with a clear explanation of the application process and verification requirements associated with DFA Form 800MA.

DFA Form 800MA is used to apply for MAGI-related Medicaid programs and other ACA-related health coverage options. If an individual is potentially eligible for a Medicaid program that is not MAGI-related, the individual does not need to additionally complete DFA Form 800, but an interview is required. Request additional eligibility information that is not collected on DFA Form 800MA, such as resources and disability information, as needed.

If the client wishes to apply for additional programs of assistance, such as Food Stamp benefits, cash, childcare assistance, NF services, and/or HCBC services, including HCBC-CFI, DFA Form 800 must be completed and an interview or attendance at the NHEP orientation may be required.

Completing an Application

A completed application must, at minimum, contain the applicant’s name, address, and signature.

Application Filing Date

The official Filing Date for applications is the date when the application is completed as described above and received by the District Office. If a paper application is received, this date is stamped onto the official application.

Eligibility Interview

Most applicants are required to also participate in a detailed interactive Application Entry (AE) eligibility interview with a Family Services Specialist (FSS).

Required Verification

All applicants must provide verification, if required by the program, such as proof of:

• eligibility factors and circumstances;

• information related to benefit allotment amount; and

• information the individual provided on the application or to the FSS during the interview.