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COMBINED MEDICAID 103-1 Application, Eligibility Determination & Furnishing Assistance

Supersedes: CMA 103-1 (11/15/2024) Reference: 42 CFR 435.905-909, .911-914, .916(b)(2)(iii); .945-.956, 42 CFR 457.330; ARM 37.82.101, .201, .204-.206, & .904 Overview: Anyone who wants to apply for Medicaid must have the opportunity to do so without delay. Applications must be voluntary and initiated by the person in need, their authorized representative, or if the applicant is incompetent or incapacitated, someone acting responsibly for them. If the applicant voluntarily withdraws the application, document in case notes with the withdrawal reason and send About Your Case’ denial notice. APPLICATION FORM: The application must be a form prescribed by the Department, or a single streamlined application for all insurance affordability programs developed by the U.S. Department of Health and Human Services. The applicant must attest to the truth, accuracy, and completeness of the information provided and declare that they understand that any misinformation will be investigated and prosecuted. APPLICATION DATE: Unless received after hours, the Medicaid application date is: • Paper application: date the signed application or first page is received and date- stamped in a field office or central scanning. • Faxed application: date of the fax, or if received on a weekend or holiday the next business day • Online application: date the application arrives in the online application mailbox. • Telephonic application: date the client completes the telephonic application. All applications (paper, fax or online) received after normal business hours, are considered received and date-stamped with the following business day’s date.