PM 15-07-00.

  1. (FCRC) Complete the AIS screens to approve an applicant for Medical Only. Process each Medical Only application through AIS unless the system is not working, or it is an exception situation which AIS cannot process.
    1. If AIS is not available, complete Form 552. See WAG 25-08-02-b for AABD or WAG 25-08-01-a for the Family Health Plans.
  2. (System) Sends Form 360C if the application is processed through the AIS and:
    • the case is not spenddown; and
    • code 00 was entered in Item 39 on the screen; and
    • the customer is not an Revised textNH or SLF resident.

      For approvals Form 360C: 

    • lists the persons approved for medical assistance;
    • lists the persons for whom an application was originally made, but who were determined ineligible to be included in the approved Medical Only case, and says why they are ineligible.
    1. If a request for food stamps was made with the Medical request, Form 360C:
      • advises the customer of the FS decision;
      • lists the person(s) for whom an application was originally made and who were determined ineligible for FS and says why they are ineligible.
  3. (FCRC) Code Form 552 and send a manually prepared customer notice for an application processed through IPACS.
    1. Enter code 80 or 92 (Medical/FS case) in Item 39 of Form 552.
    2. Complete and send the Form 458 series, telling the customer of the Medical approval.
      • Use Form 458SP for spenddown approvals processed through AIS or IPACS.
      • Use Form Revised text458LTC, Notice of Decision on Application for Medical Assistance - MANG Nursing Home/Supportive Living Facility, and Form 458M, Notice of Decision on Applications for Payment of Medicare Premiums, Deductibles and Coinsurance, for long term care approvals processed through AIS or IPACS.
      • Use Form 458M when a family member claims to be a Medicare Part A beneficiary, telling the customer of QMB/SLIB approval.
    3. List the ineligible person(s) and the reason for ineligibility on the approval notice when any person(s) is eligible to be included in the approved Medical case.