101.03.07 REASONABLE EFFORTS TO ASSIST

The Regional and Central Office of DOM is expected to: • Provide orderly surroundings to persons who come to the office; • Provide courteous service to all persons who come to or contact the office; • Provide the appropriate application form to anyone who requests one; • Allow any individual the right to apply for any benefits, regardless of circumstances. This includes allowing a clearly ineligible individual to apply; • Communicate in a clear and courteous manner information regarding programs and services offered through DOM; • Determine as soon as possible if the person asking for help is seeking a type of assistance which the agency offers. If the individual is not requesting a type of assistance offered by the regional office, he should be referred to another community agency or resource to meet his needs, if one is available. In addition, it is required that Medicaid Specialists make reasonable efforts to assist all applicants to have the applicant’s eligibility determined and/or re- determined. Assistance includes, but is not limited to, the following: • Help with forms completion; • Help with securing a representative, if needed; • Help in obtaining necessary information from third parties; and • Providing information that will assist the applicant in making informed decisions about Medicaid eligibility. Medicaid program policies are public information. Each applicant has a right to know the policies that will impact his eligibility. MAGI and/or ABD applicants who ask for assistance or are not capable of handling the application process and have no available family member or friend capable of assisting or have representatives who do not act responsibly for a MAGI or ABD applicant require special handling. Otherwise, the application will result in multiple denials that must be avoided if agency intervention is needed to resolve a failure to comply with application or renewal processing. Action needed is as follows: • If the application is for long term care in a nursing facility, the Specialist assigned to the nursing facility should contact the facility to let appropriate staff know that the application cannot proceed because the representative is not cooperating, or the applicant is not capable. If the facility is a state-owned or operated facility, the administrator or his/her designee can act as a self-designated representative if there is no available family member that can become the representative. For privately owned facilities, the administrator has the right to become the legal representative to act for the applicant unless another family member is available. If the administrator is willing to become the legal representative, pend the case until the legal authority can be obtained. If the applicant already has a court-appointed legal representative, the nursing facility (or other available family member) has the right to approach the court to have a non-cooperating legal representative removed and replaced with someone willing to act responsibly. • If the application or review is for an at-home ABD or MAGI-related case, the Specialist must speak with the applicant to determine if there is a family member or close friend or neighbor that would be willing to assist the individual in becoming an authorized representative to secure any needed verifications. • If an applicant (MAGI or ABD, at home or in long term care) already has a legal representative appointed as Power of Attorney but the individual is not cooperating in the application process, the Specialist should discuss this matter with other available family members who may be willing to secure Power of Attorney. The most recently appointed Power of Attorney with the right to make healthcare decisions for the applicant will be the one with the authority to act for the applicant. • If any of the above situations does not address or remedy a situation where an applicant/recipient is incapable or unable to provide needed information and there is either no representative or there is an irresponsible representative who is not acting in the applicant’s best interest, the Specialist must discuss the situation with their supervisor who should seek assistance from their central office contact.