Q-Track Recipient Applies for AMN

An individual who is eligible for ongoing QMB, SLMB or QI-1 does not have to file a separate application for AMN. The A/R must make his/her intentions known by requesting AMN verbally or by a written statement. Document the case record accordingly. If the A/R submits medical bills not covered by Q Track, consider it a request for AMN.

Determine AMN eligibility for:

the month the bill is received by the case worker OR

any of the three prior months OR

the ongoing month.

The medical bill has to meet all criteria for being an allowable deduction for the month under consideration.

A Q Track application filed on a DCH Form 700 may also be used as an application for full Medicaid benefits. However, additional information and verification may be required for full Medicaid.

TYPE OF CASE BAD FDL 400s REQUIRED TRANSMIT ELIGIBILITY VIA 962 to A/R De Facto First Day of BP $0 NONE System See note SD: Unpaid break-even bill incurred prior to BP First Day of BP $0 None System See note SD: Unpaid Medicaid covered, break-even bill incurred by A/R during the BP Date of break-even bill Amount of break-even bill applied to SD Break-even bill and any other of A/R’s Medicaid covered bills incurred on BAD, but not needed to meet SD System See note SD: Break-even bill not covered by Medicaid and incurred during BP Date of break-even bill $0 NONE System See note

The system generated notice, which includes Medicaid eligibility information, replaces Form 962. Complete a Form 962 only if eligibility cannot be entered in the system, such as a three-month prior application that is greater than thirteen months old.