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BAM 110 3 of 28 APPLICATION FILING AND REGISTRATION BPB 2025-003 1-1-2025

BRIDGES ADMINISTRATIVE MANUAL STATE OF MICHIGAN DEPARTMENT OF HEALTH & HUMAN SERVICES

The MDHHS-1171, Assistance Application, and MDHHS 1171-CDC, Supplement-Child Development and Care. A DHS-4025, Child Care Provider Verification. Explain that the application receipt date will affect the effective date of eligibility for CDC and encourage the requestor to file the application that day. For a request by letter or telephone, mail the application and the above forms to the requester by the end of the next workday. Note: If a client has a completed, pending MDHHS-1171 or MI Bridges application for another program and verbally requests CDC benefits, document the case and send a DHS-3503, Verification Check List, for the additional required verifications. The CDC application date will be the date the CDC program was requested. Medicaid Only Requests must be registered and the client must be sent the following: • DHS-126, Medicaid Application Inquiry. • The DCH-1426, DHS- 4574 and the DHS- 3243 if necessary. • MSA Pub. 726, Nursing Facility Eligibility (if LTC admission). The following publications must be given or sent to MA applicants and other interested parties: • MDCH Pub. A Guide to Michigan Medicaid Health Plans. • DCH Pub. 617, Medicaid Deductible Information. • MSA Pub. 726, Nursing Facility Eligibility. • MDCH Pub. 769, Medicare Savings Program. For Medicaid brochures from the Michigan Department of Health and Human Services, select Doing Business with MDHHS, then Forms & Applications. MDHHS Brochures Available for Download is located in Quick Links in the right navigation.

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Official source

BAM 110 3 of 28 APPLICATION FILING AND REGISTRATION BPB 2025-003 1-1-2025

BRIDGES ADMINISTRATIVE MANUAL STATE OF MICHIGAN DEPARTMENT OF HEALTH & HUMAN SERVICES

The MDHHS-1171, Assistance Application, and MDHHS 1171-CDC, Supplement-Child Development and Care. A DHS-4025, Child Care Provider Verification. Explain that the application receipt date will affect the effective date of eligibility for CDC and encourage the requestor to file the application that day. For a request by letter or telephone, mail the application and the above forms to the requester by the end of the next workday. Note: If a client has a completed, pending MDHHS-1171 or MI Bridges application for another program and verbally requests CDC benefits, document the case and send a DHS-3503, Verification Check List, for the additional required verifications. The CDC application date will be the date the CDC program was requested. Medicaid Only Requests must be registered and the client must be sent the following: • DHS-126, Medicaid Application Inquiry. • The DCH-1426, DHS- 4574 and the DHS- 3243 if necessary. • MSA Pub. 726, Nursing Facility Eligibility (if LTC admission). The following publications must be given or sent to MA applicants and other interested parties: • MDCH Pub. A Guide to Michigan Medicaid Health Plans. • DCH Pub. 617, Medicaid Deductible Information. • MSA Pub. 726, Nursing Facility Eligibility. • MDCH Pub. 769, Medicare Savings Program. For Medicaid brochures from the Michigan Department of Health and Human Services, select Doing Business with MDHHS, then Forms & Applications. MDHHS Brochures Available for Download is located in Quick Links in the right navigation.