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MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page 111

Effective Month: March 2018 101.20 APPLICATION AND REVIEW SUMMARY CHART ACTION POLICY REQUIREMENT PROCEDURAL REQUIREMENTS Filing an Application, Submitting a Renewal Form, and Reporting Changes Means of submission: • In-person at any location where eligibility staff are on official duty • By mail to the agency, RO or Central Office (CO) • By fax to the agency (RO or CO) • Applications may be submitted on- line at www.medicaid.ms.gov. • By telephone – The telephonic signature must be recorded. • Applications and renewal forms may be submitted online through the Common Web Portal Applications & Renewal Forms must be signed but an original signature not required. Telephone signatures are recorded versions. Who Can File an Application • Adult applicants • Certain minors (pregnant, married, living independently, applying for own children) • Parent with primary physical custody or either parent if true joint custody exists • Caretaker relative • Authorized, designated or legal representative If application filed by incorrect person, do not deny; get signature of correct person.

Applications must be signed to be valid. Authorizing a Representative (types allowed) 1) Authorized Representative – applicant or recipient designates in writing. Can be a person or organization. Limits can be placed on rep’s rights to act. 2) Self-Designated Rep – must be an individual except for owner/operator of state owned MAGI application form used to designate authorized rep for MAGI cases. DOM- 302A required for ABD authorized rep.

Self-Designated requires DOM-302B;