Page 11

BAM 115 11 of 36 APPLICATION PROCESSING BPB 2026-003 2-1-2026

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

• Beneficiaries who complete the DHS-4574, Patient of Nursing Facility. • Department wards, Title IV-E recipients and special needs adoption assistance recipients; see BEM 117, Department Wards, Title IV-E And Adoption Assistance Recipients. • Individuals who apply through the Federally Facilitated Marketplace (FFM). WHEN TO USE A DHS-457 MA Only Instead of the DCH-1426, the DHS-4574, Medicaid Application (Patient of Nursing Facility), for LTC beneficiaries (do not use for waiver beneficiaries) may be used. An approved application is current for 12 months from the original disposition date. RETRO MA APPLICATIONS MA Only Retro MA coverage is available back to the first day of the third cal- endar month prior to: • The current application for FIP and MA applicants and persons applying to be added to the group. • The most recent application (not renewal) for FIP and MA recipients. • For SSI, entitlement to SSI. • For department wards; see BEM 117, the date MDHHS received the court order for a department ward. • For Title IV-E and special needs adoption assistance recipients; see BEM 117, entitlement to title IV-E or special needs adoption assistance. Exception: Full-coverage QMB eligibility cannot be retroactive. ALMB cannot be authorized for a previous calendar year; see BEM 165, Medicare Savings Programs.

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Page 11

Official source

BAM 115 11 of 36 APPLICATION PROCESSING BPB 2026-003 2-1-2026

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

• Beneficiaries who complete the DHS-4574, Patient of Nursing Facility. • Department wards, Title IV-E recipients and special needs adoption assistance recipients; see BEM 117, Department Wards, Title IV-E And Adoption Assistance Recipients. • Individuals who apply through the Federally Facilitated Marketplace (FFM). WHEN TO USE A DHS-457 MA Only Instead of the DCH-1426, the DHS-4574, Medicaid Application (Patient of Nursing Facility), for LTC beneficiaries (do not use for waiver beneficiaries) may be used. An approved application is current for 12 months from the original disposition date. RETRO MA APPLICATIONS MA Only Retro MA coverage is available back to the first day of the third cal- endar month prior to: • The current application for FIP and MA applicants and persons applying to be added to the group. • The most recent application (not renewal) for FIP and MA recipients. • For SSI, entitlement to SSI. • For department wards; see BEM 117, the date MDHHS received the court order for a department ward. • For Title IV-E and special needs adoption assistance recipients; see BEM 117, entitlement to title IV-E or special needs adoption assistance. Exception: Full-coverage QMB eligibility cannot be retroactive. ALMB cannot be authorized for a previous calendar year; see BEM 165, Medicare Savings Programs.