Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Computer Matches Overview Effective Date: December 2019 Chapter: 2000 Policy Number: 2001 Previous MT Number(s): MT 01 Updated or Reviewed in MT: MT-57

Applicants and recipients whose resources and income are used to determine eligibility are matched with the files of various governmental agencies.

The applicant’s and recipient’s (A/R’s) primary social security numbers (SSN) are matched with SSNs contained in other governmental agency files. The information associated with the SSNs is compared. Discrepancies are identified for follow-up and investigation.

Computer matches through the use of the A/R’s SSN are designed to detect income, resources, and to provide other pertinent information required to establish eligibility and benefit levels.

Information obtained from the computer matches is used for the following purposes:

to verify eligibility of A/Rs,

to verify the proper amount of benefits,

to determine whether recipients are receiving the benefits to which they are entitled,

to obtain information to use to conduct criminal or civil prosecutions based on receipt of benefits to which recipients are not entitled.

Computer matches are accessed via system terminals or through personal computers connected to the system.

Users must have a valid password which is obtained from the State Office.

Unlawful access is prohibited. A record of all inquiries by password is kept and monitored by the system.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Income And Eligibility Verification System Effective Date: May 2023 Chapter: 2000 Policy Number: 2002 Previous MT Number(s): MT 57 Updated or Reviewed in MT: MT-69

The Income and Eligibility Verification System (IEVS) is a federally operated system through which agencies request data, wage and benefit information on program applicants and recipients from other state and federal agencies.

IEVS computer matches are performed by Gateway with the following files from other agencies:

SSA Beneficiary Earnings Exchange Record (BEER)

United States Internal Revenue Service (IRS)

Interstate Files

SSA Prisoner Verification Inquiry

SSA Death Verification Inquiry

SSA Bendex

SDX

A wage and benefit match is completed to compare the information in Gateway and other computer files. If a match is found and the information in a computer file differs from the information in Gateway, a system-generated alert is sent to inform the worker of the discrepancy. The worker takes action to resolve the discrepancy and documents those actions in the A/R’s case notes. Refer to Gateway Documentation Standards for documentation requirements.

The SSA Prisoner Verification Inquiry and SSA Death Verification Inquiry match the files of the Social Security Administration with Gateway files to determine if A/Rs are incarcerated or deceased.

Information received by the IRS and BEERS systems is no longer received by the Medicaid program and is not updated in the Gateway system for Medicaid purposes. This information is no longer subject to the special security considerations. Refer to Section 2003 , IRS/BEERS Security for more information.

Follow the procedures below to process data received from the computer matches. Use information received from the matches to determine eligibility and benefit level.

Complete case actions to resolve discrepancies within 45 days of receipt of the information.

Completion of case actions may be postponed to the next review if the actions cannot be completed due to non-receipt of verification already requested from a collateral contact.

Consider the following information as a lead and verify the income information when a match is received:

RSDI benefits, Verify gross RSDI income on Clearinghouse.

DOL earned income matches

IRS earned income and pension matches

questionable IEVS information

prisoner verification data.

Record the following information:

results of the case record screening

the reason a discrepancy does not exist, if applicable

date verification was requested and from whom verification was requested

date action has been taken to correct ongoing benefits

date of completion of the case action to resolve the discrepancy

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Internal Revenue Service (IRS) And Beneficiary Earnings Exchange Records (BEERS) Information Security Effective Date: December 2022 Chapter: 2000 Policy Number: 2003 Previous MT Number(s): MT 58 Updated or Reviewed in MT: MT-68

It is the responsibility of the Department of Human Services (DHS) to protect the Federal Tax Information (FTI) provided through the Internal Revenue Services (IRS) to the state agencies.

Unauthorized use or access of Federal Tax Information, i.e., IRS/ Beneficiary Earnings Exchange Record System (BEERS) information, earning records and/or unearned income records maintained by Social Security Administration, is forbidden. The confidentiality and security of FTI must be protected and maintained at the level of federal standards and requirements.

As a condition of receiving IRS/BEERS information, DFCS is required to establish and maintain certain safeguards designed to prevent unauthorized use of the information and to protect the confidentiality of the information.

There are two criminal penalties associated with unauthorized access and/or unauthorized disclosure of Federal Tax Information (FTI).

The penalties for unauthorized access of FTI (IRS/BEERS) include the following:

a fine of up to $1,000, or imprisonment of up to 1 year, or both

costs of prosecution for felony access.

Penalties for unauthorized disclosure of IRS information include the following:

a fine of up to $5,000, or imprisonment of up to 5 years, or both

costs of prosecution for felony disclosure

termination from employment upon conviction of unauthorized disclosure

payment of civil damages to the individual about whom information was illegally disclosed if that individual brings a civil action.

The accused employee can be guilty of both offenses and prosecuted for both.

In addition to that, there is a civil penalty for unauthorized access or unauthorized disclosure. In the case of a state employee, the employee is personally liable as opposed to the agency.

Information received by the IRS and BEERS systems is no longer received by the Medicaid program and is not updated in the GA Gateway system for Medicaid purposes. For more information on the special security considerations regarding IRS and BEERS information received by DFCS agency please refer to TANF Manual 3390, Policy Section 1410 .

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Clearinghouse Effective Date: June 2025 Chapter: 2000 Policy Number: 2004 Previous MT Number(s): MT 69 Updated or Reviewed in MT: MT 74

Clearinghouse is an automated on-line computer interface through which wage and benefit information on applicants, recipients and financially responsible members of a budget group is matched with files in other state and federal agencies.

Clearinghouse matches are performed with the following agencies and contain the following information:

Department of Labor (DOL) Wage Files - the most recent five quarters of employment history by employer name, employer number and amount of wages earned.

Department of Labor (DOL) Employer Address Files – the work location and/or the address of the accounting office

Department of Labor (DOL) Unemployment Compensation Benefits (UCB) - the monthly UCB amounts for the most recent 13 months and a list of individual checks for the last ten weeks

Department of Labor (DOL) Unemployment Compensation Benefits (UCB) Claimant Address File – the address of each UCB recipient

Department of Labor (DOL) W-4 Employer Reporting System – the name and address of any new employer and the date of hire

BENDEX – RSDI benefit information on individuals who are current or past recipients of public assistance.

Child Support Inquiry ($TARS) – verifies child support data provided through Division of Child Support Services.

State Data Exchange (SDX) – SSI benefit information.

Federal Data Services Hub (FDSH) – provides income and employment information received from IRS records, health and entitlements from HHS records, identity from Social Security, citizenship from Department of Homeland Security records, criminality from Department of Justice records and residency from state records.

State Online Query (SOLQ) – verifies SSN, RSDI and SSI benefit information.

State Verification Exchange System (SVES) – verifies Citizenship/ID or nationality of Medicaid or CHIP applicants declaring to be U.S. citizens or nationals.

Systematic Alien Verification for Entitlements (SAVE) – verifies Alien Status.

Employer Income Verification System (EIVS) - verifies wages provided by employers contracted through Employer Income Verification Income System framework, which includes Truv, Experian and/or TransUnion.

Clearinghouse files are accessed on any individual who is in active or pending status, is age 16 or older and who may affect eligibility for benefits such as the following:

applicants

recipients

ineligible aliens

sanctioned individuals

Clearinghouse is accessed on pending or active AU’s at the following times:

at registration or finalization of a new AU or reopening of an AU

in the month prior to the review month, when the AU is selected for review

if a primary SSN is changed

adding a person to the AU at an interim change

Use the following procedures for documenting and establishing Clearinghouse history:

Chart 2004.1 - Documenting and Establishing Clearinghouse History Data Source Method of Documentation DOL Wage Files DOL Wage Inquiry is an interface within Gateway that creates a historical record that can be accessed through Interfaces Module if results are found. Document any discrepancies between information found on the interface, reported by the AR, and entered into Gateway. DOL UCB Files DOL UCB Inquiry is an interface within Gateway that creates a historical record that can be accessed through Interfaces Module if results are found. Document any discrepancies between information found on the interface, reported by the AR, and entered into Gateway. DOL W-4 New Hire Files New Hire is an interface within Gateway that creates a historical record that can be accessed through Interfaces Module if results are found. Document any discrepancies between information found on the interface, reported by the AR, and entered into Gateway. BENDEX BENDEX is an interface within Gateway that creates a historical record that can be accessed through Interfaces Module if results are found. Document any discrepancies between information found on the interface, reported by the AR, and entered into Gateway. State Data Exchange (SDX) SDX is an interface within Gateway that creates a historical record that can be accessed through Interfaces Module if results are found. Document any discrepancies between information found on the interface, reported by the AR, and entered into Gateway. State Vital Records Document case notes of any discrepancies. Systematic Alien Verification for Entitlements (SAVE) SAVE is an interface within Gateway that is used to verify Alien status. SAVE interface is accessible via the Alien Details screen within Gateway. Document case notes if results require secondary or tertiary verification and results indicated when received. Child Support Data ($TARS) $TARS is an interface within Gateway that creates a historical record that can be accessed through Interfaces Module if results are found. Document any discrepancies found between the information on found on the interface, reported by the AR, and entered into Gateway.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: SSN Validation Effective Date: December 2019 Chapter: 2000 Policy Number: 2005 Previous MT Number(s): MT 47 Updated or Reviewed in MT: MT-57

The system interfaces with the files at the Social Security Administration (SSA) to verify the accuracy of the SSN of an AU member.

All SSNs entered in the system will interface with SSA files.

Use the following procedures to complete the validation requirements:

Chart 2005.1 – SSN Validation IF AN AU MEMBER’S SSN THEN Is valid The system will annotate the SSN with ”Electronically verified by SVES”, “Electronically verified by SOLQ” or “Electronically verified by FDSH” (federally verified). No further action is required. Appears on the system generated enumeration or validation discrepancy lists An alert is generated. determine if the AU member’s full name, DOB, and SSN matches information on the individual’s official documents. Correct any information that is in error. Refer the A/R to SSA for corrective action if the SSA information is the source of the error. matches with another SSN known in the system determine which number on the system is correctly assigned. Correct any SSNs erroneously entered in the system OR refer the AU member to SSA for corrective action if multiple individuals are assigned the same SSN. Determine which number on the system is correctly assigned. Correct any SSNs erroneously entered in the system OR refer the AU member to SSA for corrective action if multiple individuals are assigned the same SSN. is validated by the system but differs from the verification (SSN card) obtained from the A/R follow the steps under How to Change a Validated SSN in this section.

Please note if the SSN is showing “Electronically verified by SOLQ” or “Electronically verified by FDSH”, generated by running the State Online Query or Federal Data Hub Services interfaces respectively, these are also considered federally verified SSNs.

Step 1 Gather the following case identifying information and report it in the order listed: worker’s name worker’s telephone number county, office, supervisor, user ID AU number AU name AU member’s name AU member’s ID number Step 2 Contact the EMPI Help Desk at empi.helpdesk@dhs.ga.gov . Step 3 Correct the SSN when the EMPI Helpdesk provides notification that the validation code has been removed.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Confidentiality Effective Date: May 2023 Chapter: 2000 Policy Number: 2010 Previous MT Number(s): MT 57 Updated or Reviewed in MT: MT-69

Any information related to individual applicants and recipients of programs administered by DFCS is confidential and is governed by regulations, which specifically forbid the release of this information to unauthorized persons or agency representatives.

All case record material is confidential, including the names and addresses of applicants and recipients, as well as the types and amount of benefits provided.

Refer to 2011 Health Information Portability and Accountability Act of 1996 for additional information regarding privacy of health information.

Case record information may be released to the following:

the applicant/recipient (A/R)

the personal representative (PR)

an individual or agency if the A/R signs Form 5459, Authorization of Release of Information

The county office may charge for photostatic copies of case record material.

The following information may not be released to anyone , including the A/R:

medical or psychiatric information marked confidential if the information in the record could be harmful to the A/R

information provided by an individual who has requested confidentiality

confidential information regarding pending criminal prosecution

information obtained from the IRS

Penalties for release of IRS information include:

fine not exceeding $5,000 or imprisonment of not more than 5 years, or both, including costs of prosecution for felony disclosure

dismissal from employment

discharge from employment upon conviction for such offense

civil action for damages against the taxpayer brought by that taxpayer in a district court of the United States.

If the A/R requests any of the above information, refer the A/R to the source of the information.

Release the requested information pertinent to service delivery to the following agencies or their representatives without obtaining the A/R’s permission:

the Department of Community Health (DCH)

individuals directly connected with the administration of the DFCS, Child Support Program, Office of Investigation Services, Department of Behavioral Health and Developmental Disabilities (DBHDD), Division of Aging, Health and Human Services and SSA employees as necessary to assist in establishing or verifying eligibility benefits under Titles II and XVI of the Social Security Act

individuals directly connected with other federal assistance programs and federally assisted state programs providing assistance on a means tested basis to low-income individuals

persons directly connected with the administration of the Income and Eligibility Verification System (IEVS)

employees of the Comptroller General’s Office of the United States for an audit examination

the current address of any fugitive felon or assistance unit (AU) member who has knowledge of the fugitive felon’s whereabouts may be given to a law enforcement officer if the name and social security number (SSN) of the felon is known by the officer.

name(s) and address(es) only of participating AUs to persons directly connected with nutrition education,

researchers authorized in writing by the agency,

public officials who request information in writing and the request originated from an inquiry by the AU,

emergency situations in which the County Director, Regional Director, or Division Director judges that the release is necessary to prevent loss of or risk of life or health upon approval from the State Office. Notify A/R immediately of this release.

An employee may be eligible for certain public assistance benefits. Employees who apply for or are receiving benefits as a member of a household must notify their supervisor. All employees' cases must be handled by a supervisor or supervisor designee. Each county should develop a plan for limited access to these cases by other staff members and the employee himself. The Regional Manager must approve the plan for handling employee cases and is to be notified of any employee receiving benefits.

Employees should not handle relatives or personal friend’s applications or cases and should notify his/her supervisor when such situations occur. Employees should not be authorized representatives unless approved by the Regional Manager.

The employee/client must comply with all requirements of the program in which he or she is participating including the prompt and accurate reporting of all changes in income or circumstances. If an employee takes action on or views the case of another employee, a relative or an individual of personal interest, he may be subject to disciplinary action and prosecution for a second- or third-degree felony.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Health Information Portability and Accountability Act of 1996 Effective Date: December 2019 Chapter: 2000 Policy Number: 2011 Previous MT Number(s): MT 37 Updated or Reviewed in MT: MT-57

DFCS is required to comply with the Health Information Portability and Accountability Act (HIPAA) of 1996, including its rules regarding security and privacy of confidential health information.

HIPAA was enacted by Congress to provide group and individual insurance reform, introduce tax-related health care provisions, control healthcare fraud and abuse, and to ensure improvement in healthcare systems.

The Georgia Department of Human Services (DHS) has chosen Covered Entity status to promote simplification of information sharing within the Department.

This policy applies to all individuals who are Georgia Department of Human Services (DHS) employees, volunteers, trainees, and contractors who perform duties in conjunction with the access, distribution, dissemination, modification, and management of protected health information.

DHS administers programs and provides services that have more stringent requirements than those provided by the Privacy Rule. In the administration of such programs and provision of such services, the Department will adhere to the more stringent requirements.

The Privacy Rule, effective April 14, 2003, ensures privacy protection by limiting the ways that Protected Health Information (PHI) can be used and released.

Each adult AU/BG member and, if applicable, each PR must be provided with a Notice of Privacy Practices upon receipt of an application for assistance, or when he/she is added to an existing AU/BG. This includes instances in which an A/R is currently receiving benefits in another program, such as food stamps, and applies for Medicaid. The notice must be mailed to each adult who is not present for a face-to-face interview. It is preferable, but not required, that each adult sign and return his/her notice, however the case record must be documented that the notice(s) was sent.

PHI is individually identifiable health information. Examples of PHI include, but are not limited to the following:

demographic information, such as name, age, gender

health status information

prescription drug information

healthcare payment information

prior existing conditions

eligibility information

authorization and referral certifications PHI may be in electronic, paper-based, or oral form.

Covered entities may use and share only the minimum amount of protected information necessary to accomplish a particular purpose.

DHS is responsible for determining the amount of PHI required per function. Upon determination of minimum necessary PHI, DHS will communicate this decision to all affected parties.

The Privacy Rule prohibits the use and disclosure of PHI for purposes not related to treatment, payment, or health care operations. The identity of a person requesting PHI and his/her authority to receive such information must be verified prior to release of PHI. Computer matches are accessed via system terminals or through personal computers connected to the system.

As a covered entity, DHS is permitted, but not required, to use and disclose PHI, without an individual’s authorization in certain situations and for specific purposes.

The following uses and disclosures do not require authorization from the individual:

treatment, payment, and health care operations (TPO)

public health agencies activities

health oversight and regulatory agency activities

judicial proceedings and law enforcement investigations

healthcare fraud investigations

emergency situations

de-identified information (health information not connected with information identifying the individual)

The following uses and disclosures do require authorization from the individual:

third party disclosures

marketing and fund raising activities

non-health related affiliates

underwriting or related affiliates

employment determinations

sale, rental or barter of PHI

psychotherapy records other than psychotherapy notes

Prior to the release of PHI that requires authorization, the A/R must complete and sign DHS Form 5459 (rev. 07/2016), Authorization for Release of Information.

Signed, blank Forms 5459 are not permissible and may not be obtained or used for any purpose. Form 5459 may be used to release or obtain information only if the A/R or PR has specified on the Form 5459 to whom information is to be released or from whom information is to be obtained. At the point the A/R signs Form 5459 it must be dated. Form 5459 should be used within 30 days from the date it is signed.

DHS will maintain compliance with HIPAA Privacy Rule administrative requirements including, but not limited to:

designation of a privacy officer who is responsible for the development, implementation and maintenance of privacy policies and procedures

development, implementation, and documentation of timely and effective privacy training

development, maintenance, and enforcement of complaint procedures

enforcement of appropriate sanctions for failure to comply with HIPAA regulations

The HIPAA Security Rule ensures the security of PHI by specifying how PHI is stored, transmitted, and accessed.

Guidelines for safeguarding PHI include, but not limited to:

PHI will be discussed with the A/R or PR only in private areas

PHI will be discussed with staff members on a need-to-know basis and in non-public areas only

telephone calls regarding PHI will be held in areas in which the conversation cannot be overheard

computer monitors will be positioned in a way that does not permit observation by anyone other than the A/R or PR

computer passwords will not be shared and will be recorded only in secure locations

PHI will be disclosed only by those staff members authorized to do so

access to fax machines will be limited to authorized staff

case records, mail, documentation, and other materials containing PHI will be maintained in locked or otherwise secure locations, away from the general public

staff members will wear appropriate agency-issued identification at all times

PHI will be discarded in appropriate secure containers.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Mandated Reporting Effective Date: December 2019 Chapter: 2000 Policy Number: 2015 Previous MT Number(s): MT 1 Updated or Reviewed in MT: MT-57

The Official Code Section 19-7-5 updated through the 2000 Session of the General Assembly states: The purpose of this code section is to provide for the protection of children whose health and welfare are adversely affected and further threatened by the conduct of those responsible for their care and protection. It is intended that the mandatory reporting of such cases will cause the protective services of the state to be brought to bear on the situation in an effort to prevent further abuses, to protect and enhance the welfare of these children, and to preserve family life whenever possible.

Section One (1) of the above-stated law mandates that all DFCS employees are responsible for reporting suspected child abuse or neglect to Child Protective Services (CPS). The following is a list of what must be reported to CPS:

observed signs of physical abuse on a child

observed abusive action imposed on a child

information about suspected abuse or neglect toward a child disclosed to you during an interview or conversation

information about suspected abuse or neglect toward a child disclosed to you during a phone call. Refer this person to CPS Intake. Follow-up the conversation with a written referral to CPS Intake. Maintain a copy of the referral in the case record

If there is doubt as to whether or not a report should be made, make the report. CPS intake workers screen all reports and determine whether or not to open an investigation. If there is doubt, err on the side of the child’s safety.

The following steps should be taken when making a CPS referral:

Step 1 Suspected acts of abuse or neglect toward a child are observed or discovered through conversation. Step 2 If the behavior is being exhibited in the county office, arrange for the CPS intake worker to talk with the client. Follow up the request to CPS in writing. Make a copy of written referral for case record. Step 3 If CPS intake is not available or the client is not present, make a written referral to CPS and make a copy of the referral for the case record. Include the following information in the referral: child’s name, age, gender, address and current location if different from the address parent/guardian’s name, address, phone number reason for referral reporter’s name, address, phone number and relationship to the child.

The Reporter has the right to remain anonymous. Note that on the referral if this request is made.

Georgia Division of Family and Children Services Civil Rights Policy Manual Effective Date: June 15, 2026 Policy Title: Americans with Disabilities Act and Section 504 of the Rehabilitation Act Next Review: June 15, 2028 Policy Number: 3601 Previous Policy Number(s): FS Policy 3025, MA Policy 2020, TANF Policy 1004

It is the policy of the Georgia Department of Human Services (DHS), Division of Family and Children Services (DHS/DFCS) that no qualified individual with a disability shall, on the basis of disability, be excluded from participation in or be denied the benefits of DHS/DFCS programs, services, or activities.

This policy addresses the responsibility of DHS/DFCS staff, including volunteers and interns, and its subrecipients, contractors, grantees, agents, and providers of services (Providers), who assist with or administer programs, services, and activities that fall under DHS/DFCS’ Office of Family Independence (OFI), to comply with disability laws and regulations, including but not limited to Title II of the Americans with Disabilities Act of 1990 (ADA), and Section 504 of the Rehabilitation Act of 1973 (Section 504). This policy is not applicable to DHS/DFCS Child Welfare and DHS Office of Human Resources (OHR) employment matters.

This policy replaces all prior DHS/DFCS civil rights provisions, policies, procedures, forms, or other documents that are inconsistent with or conflict with the provisions of this policy.

ADA and Section 504 provisions relating to child welfare matters are addressed in DHS/DFCS Child Welfare Policy 1.5 .

ADA provisions relating to DHS employment matters are addressed in DHS OHR Policy 1704 .

This policy applies to all DHS/DFCS OFI staff and its Providers, as required by law, contract, or agreement, who are involved with the administration of DHS/DFCS programs, services, and activities.

This is not an exhaustive list of all civil rights authorities that may be applicable to DHS/DFCS programs and Providers. *

Title II of the Americans with Disabilities Act of 1990 (“ADA”) as amended by the ADA Amendments Act of 2008, 42 U.S.C. § 12131 et seq. , 28 C.F.R. § 35.101 et seq. [United States Department of Justice (DOJ)]

Section 504 of the Rehabilitation Act of 1973, as amended, 29 U.S.C. § 794 ; 7 C.F.R. § 15b et seq. [United States Department of Agriculture (USDA)], 45 C.F.R. § 84.1 et seq. [United States Department of Health and Human Services (HHS)]

Title III of the ADA as amended by the ADA Amendments Act of 2008, 42 U.S.C. § 12181 et seq. , 42 U.S.C. §12205a ; 28 C.F.R. § 36.101 et seq. [DOJ]) (as applicable)

Section 11(c) of the Food and Nutrition Act of 2008, as amended, 7 U.S.C. § 2020(c) [USDA]

R.H. et al. v. Rawlings et al. , CAFN: 1:17-CV-01434-TWT (N.D. Ga. 2019) (Consent Order, filed on June 4, 2019)

The terms used in this policy shall mean the following unless the context otherwise requires:

“ADA” means Title II of the Americans with Disabilities Act of 1990, a civil rights law which prohibits discrimination on the basis of disability in state and local government programs, services, and activities.

“Auxiliary aids and services” mean devices or services that enable effective communication for persons with disabilities including, but not limited to, qualified interpreters, notetakers, real-time computer-aided transcription services, assistive listening devices, Braille materials and displays, large print materials, qualified readers, taped texts, audio recordings, acquisition or modification of equipment or services, and other similar services and actions.

“Companion” means any family member, friend, or associate of a person seeking or receiving DHS/DFCS services who is an appropriate person with whom DHS/DFCS should communicate.

“Disability” means a physical or mental impairment that substantially limits one or more of an individual’s major life activities . The term also includes having a history or record of such an impairment or being regarded as having such an impairment even if an individual does not actually have such an impairment.

“Discrimination” means the act (or action), whether intentional or unintentional, through which an individual, solely because of race, color, age, sex, disability, national origin or any other protected class, has been otherwise subjected to unequal treatment under any program, service, or activity receiving federal financial assistance.

“Individual with a disability” under the ADA is defined as a person with a physical or mental impairment that substantially limits one or more major life activity; a person who has a record of such an impairment; or a person who is regarded as having such an impairment. The term individual with a disability does not include an individual who is currently engaging in the illegal use of drugs or alcohol.

“Major life activities” include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, reading, concentrating, learning, thinking, communicating, as well as the operation of bodily functions, such as neurological and brain functions.

“Mobility Aids and Other Power-Driven Mobility Devices” means any mobility device powered by batteries, fuel, or other engines… that is used by individuals with mobility disabilities for the purpose of locomotion, including golf cars, electronic personal assistance mobility devices… such as the Segway® PT, or any mobility device designed to operate in areas without defined pedestrian routes, but that is not a wheelchair.

“Qualified Individual with a Disability” is an individual with a disability who, with or without reasonable modifications to rules, policies, or practices, the removal of architectural, communication, or transportation barriers, or the provision of auxiliary aids and services, meets the essential eligibility requirements for the receipt of services or the participation in programs or activities provided by the Department.

“Qualified Interpreter” is an interpreter who, via a video remote interpreting (VRI) service or an on-site appearance, is able to interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary. Qualified interpreters include, for example, sign language interpreters, oral transliterators, and cued-language transliterators.

“Reasonable modification” means a change in a policy, practice, or procedure that is made to offer equal access to a public entity’s programs, services, or activities for a person with a disability. A modification that fundamentally alters the nature of a service program, or activity; or a modification that results in an undue financial or administrative burden (applies only to recipients of federal financial assistance) is not a reasonable modification.

“Reasonable Modification and Communication Assistance Request Form” is a form, either in paper or electronic format that can be used, at the option of the constituent with a disability, to request a reasonable modification or communication assistance and for purposes of tracking the request and response.

“Request for Reasonable Modification and Communication Assistance” is any specific written or oral statement by or made appropriately on behalf of a constituent with a disability, including through the “Reasonable Modification and Communication Assistance Request Form” that indicates the individual has a disability for which he or she needs a reasonable modification or communication assistance to access all DHS/DFCS programs, benefits, or activities. A request for reasonable modification includes instances where the individual initiates the request for assistance.

“Section 504 of the Rehabilitation Act of 1973” or “Section 504” prohibits discrimination based on disability against otherwise qualified individuals on the basis of disability in all programs, services, and activities receiving federal financial assistance.

“Service Animal” means any dog that is individually trained to do work or perform tasks for the benefit of an individual with disabilities.

“Telecommunication Relay Service” (“TRS”) is a telephone service that allows individuals with hearing or speech disabilities to place and receive telephone calls. Georgia Relay (dial 7-1-1) is the TRS provided by the State of Georgia to make telecommunications accessible for individuals who are deaf, hard of hearing or have difficulty speaking at no cost to the TRS user.

“Video Remote Interpreting” (“VRI”) is an interpreting service that uses video conference technology over dedicated lines or wireless technology offering high-speed, wide-bandwidth video connection that delivers high-quality video images as provided in 28 C.F.R. § 35.160(d) .

“Wheelchair” means a manually operated or power-driven device designed primarily for use by an individual with a mobility disability for the main purpose of indoor or of both indoor and outdoor locomotion.

DHS/DFCS must:

The following measures are required by DHS/DFCS to prevent discrimination based on disability and ensure equal access to DHS/DFCS programs and services:

DHS/DFCS must designate an individual to serve as the point of contact for staff and the general public regarding ADA disability access matters and to coordinate implementation of this policy. Local government agencies and other public entities with whom the DHS/DFCS contracts that employ 50 or more persons must also designate at least one employee to coordinate its efforts to comply with the ADA. (Reference: 28 C.F.R. § 35.105)

DHS/DFCS and its Providers that receive federal financial assistance (FFA) from the USDA and that employ 15 or more individuals must also appoint a Section 504 coordinator to coordinate services and resources for constituents with disabilities (7 C.F.R. § 15b.6). DHS/DFCS and its Providers that receive FFA from the HHS and employ 15 or more individuals must also appoint a Section 504 coordinator to coordinate services and resources for constituents with disabilities (45 C.F.R. § 84.7 ). One person may coordinate implementing regulations, directives, and guidance for both statutes. The name, office address, and telephone number of the ADA/Section 504 Coordinator must be provided to all interested constituents.

The primary responsibilities of the District ADA/Section 504 Coordinator are listed in Attachment 1. The State DHS/DFCS ADA/Section 504 Coordinator must convene regular meetings with ADA/Section 504 Coordinators serving the DHS/DFCS local agencies and Providers that deliver services directly to the public. For a list of DHS/DFCS OFI District ADA Coordinators, please visit: {url-DHS/DFCS-rights}.

DHS/DFCS and its Providers must notify constituents with disabilities about the availability of free reasonable modifications and auxiliary aids and services and how to request them in a format that constituents can understand. Notices must be provided in alternative formats upon request. DHS/DFCS and its Providers also must notify the public of the right to file a discrimination complaint.

DHS/DFCS and its Providers must post signage at all inaccessible entrances to each of its facilities, directing users to an accessible entrance or to a location at which they can obtain information about accessible facilities. The international symbol for accessibility must be used at each accessible entrance of a facility.

The DHS/DFCS Notice of ADA/Section 504 Rights is a notice that provides in formation regarding the rights of constituents with disabilities. The notice is available on Georgia Gateway, in all applications and renewal forms for Supplemental Nutrition Assistance Program (SNAP) also known as “Food Stamps”, Temporary Assistance for Needy Families (TANF), and Medicaid programs, in all county offices, and online at: {url-DHS/DFCS-rights}.

Copies of the Notice of ADA/Section 504 Rights and the Request for Reasonable Modification and Communication Assistance forms must be available in waiting rooms of local county offices. If requested, staff must read the Notice of ADA/Section 504 Rights to constituents who may be blind or visually impaired to ensure understanding. In addition, staff must complete or assist constituents in completing a Request for Reasonable Modifications and Communication Assistance form, if requested, due to a disability. [PC7.1][ER7.2] More information can be found online at: {url-DHS/DFCS-rights}.

Notices regarding a right to file a discrimination complaint must be posted in accordance with federal agency directives. Refer to Policy 3701 ( DHS/DFCS Civil Rights Policy ) in PAMMS. The joint U.S. Department of Agriculture (“USDA”), U.S. Department of Health and Human Services’ (“HHS”) Joint Notice of Nondiscrimination must be posted in accordance with FNS directives. It is located online at {url-DHS/DFCS-rights}.

The appropriate “And Justice for All” (AJFA) poster must be prominently displayed in all offices where there is a USDA presence and where it may be read by constituents. Please note that institutions participating in or administering USDA programs, such as SNAP, The Emergency Food Assistance Program (TEFAP), and the Commodity Supplemental Food Program (CSFP) are required to display the appropriate AJFA poster in their facilities where it can be viewed by constituents. Form AD-475-A corresponds to the AJFA poster that is applicable to the Commodity Supplemental Food Program (CSFP) and The Emergency Food Assistance Program (TEFAP). Form AD-475-B corresponds to the AJFA poster that is applicable to SNAP. All AJFA posters must be displayed in a specific size: 11” width x 17” height. Information can be found online at: www.usda.gov/about-usda/general-information/staff-offices/office-assistant-secretary-civil-rights/policy/and-justice-all . Contact the DHS/DFCS Food and Nutrition Director to obtain a hardcopy of the AJFA poster.

Reasonable modifications afford a constituent with a disability an equal opportunity to participate in all DHS/DFCS programs and receive all benefits and services for which that constituent is otherwise eligible. Providing a reasonable modification may take many forms including, but not limited to, policy or procedural modifications, deferral from certain activities, and extensions of deadlines. Examples of making reasonable modifications at the administrative level include making existing facilities readily accessible to and usable by a constituent with a disability and acquiring or modifying equipment.

With reasonable modifications, a constituent with a disability can participate fully in programs, services, and activities. Reasonable modifications are fact-specific and tailored to the constituent circumstances of the constituent with a disability.

Requests for Reasonable Modification(s) Constituents with disabilities may require reasonable modifications to assist them with accessing DHS/DFCS programs and services, complying with program requirements, avoiding potential sanctions for noncompliance. All constituents have the right to request a reasonable modification. Assessing possible reasonable modifications is a collaborative, interactive process. The starting point should always be, if possible, the constituent’s preferred modification. The constituent’s preference should provide the context for determining what a reasonable modification might be. When processing a request for reasonable modification or communication assistance, staff must not request or require verification of a constituent’s or companion’s disability. While staff cannot ask constituents to identify their disability, staff may ask what major life activity is substantially impaired or limited by their disability. Constituents with a disability may direct a request for a reasonable modification to any appropriate DHS/DFCS staff member at any time. Constituents with a disability may make a request for reasonable modifications orally or in any written form. Staff who do not have access to Gateway, such as front desk workers, should forward the requests to an eligibility worker for processing. Constituents with a disability may also complete the Reasonable Modification and Communication Assistance Request Form (Form 101) . Constituents are not required to use the form to make a request for reasonable modifications. Constituents may obtain the Reasonable Modification and Communication Assistance Request Form in constituent waiting rooms in each county DHS/DFCS office and Right from the Start Medical Assistance (RSM) location. The form is also available online at {url-DHS/DFCS-rights}. Staff must be able to provide the Reasonable Modification and Communication Assistance Request Form to a constituent upon request and may provide this form to a constituent if a staff member believes the constituent may require a reasonable modification. Forms are to be made available to constituents in alternate formats as requested (i.e. large print or Braille). Staff are required to assist constituents with the completion of Form 101, if necessary. If a constituent discloses a disability, staff members will inform the constituent of his/her right to make a request for reasonable modifications and will be provided examples of reasonable modifications. Once a constituent requests a reasonable modification, DHS/DFCS Office of Family Independence (OFI) eligibility staff are required to document any oral request or written requests for reasonable modifications in the constituent’s Gateway case file with the following information: The date(s) and type(s) of reasonable modifications requested by the constituent, the date a request for reasonable modification was granted or denied, the reason the request for reasonable modification was denied, if applicable, and the specific approved or denied reasonable modification(s). When a written request for reasonable modification is mailed, faxed, emailed, or hand-delivered to a local county DHS/DFCS office or other appropriate staff, that staff must forward the request to an eligibility worker for processing. Eligibility workers are required to review the constituent’s case file in Gateway prior to or during every interaction with the constituent and before taking any action on the constituent’s case. Current processes for documenting in Gateway for reasonable modifications can be found in the Gateway Training. If the constituent expresses a need for assistance related to a disability, expresses difficulty completing any task in the application/renewal process, and/or has a disability that is documented in Gateway, eligibility worker must provide assistance in filling out forms, explaining processes, and navigating services to the constituent. Staff are required to provide reasonable modifications to qualified constituents with a disability at every point of interaction with constituents in the OFI eligibility process, including inquiries about applications for benefits, whether in person, online, by telephone, or by mail.[PC19.1][ER19.2] Staff must assess requests for reasonable modifications as part of a collaborative, interactive process, applying a fact-specific, individualized analysis of the person’s circumstances and the modification requested to assist the constituent to access OFI programs and provide the necessary information to determine program eligibility. Decisions concerning a constituent’s request for a reasonable modification may incorporate the following factors, assessed cooperatively with the constituent: (1) how the constituent’s disability impairs access to OFI programs; (2) how the disability limits the constituent’s ability to comply with program eligibility procedures; (3) reasonable modification options that address those limitations; and (4) the effectiveness and feasibility of the proposed options. Provisions of reasonable modifications are based on a fact-specific inquiry that is to be assessed on a case-by-case basis and may be limited by regulation. All eligibility workers have the responsibility and authority to offer, grant, and implement necessary reasonable modifications to constituents with disabilities. DHS/DFCS staff do not have authority to grant a request for reasonable modification to program policy rules, such as income verification. Common examples of reasonable modifications, include, but are not limited to: Assistance gathering documents required by the program to support initial and ongoing eligibility for benefits; Flexible appointments and training requirements including scheduling appointments, so they do not conflict with constituent’s medical appointments, rehabilitation, or therapy; Allowing constituents to reschedule appointments, potentially multiple times, when a disability prevents attendance; Giving a constituent more time to submit documents or complete other tasks; Reading and explaining notices, rights and responsibilities forms, and other program materials to the constituent, repeatedly, if necessary, to help ensure understanding; Modifying work activities unless not authorized by program policy and regulations; Providing access for persons with disabilities who rely on service animals, wheelchairs, mobility aids or Other Power-Driven Mobility Devices (OPMD).

Denial of Request for Reasonable Modification(s) Only the DHS/DFCS Division Director or his/her designee has the authority to deny, in whole or in part, reasonable modification requests or otherwise refuse requests for reasonable modifications. DHS/DFCS and its Providers are not required to provide a reasonable modification that would fundamentally alter the program, service, or activity or result in an undue financial or administrative burden. The determination that undue burdens would result must be based on all resources available for use by DHS/DFCS or its Providers. If a modification request would cause an undue financial burden to a program or activity to the level that it would make continued operation of the program unfeasible, the modification need not be provided. However, denying a modification under the fundamental alteration exception should not result in the denial of access to the program or other benefits or services. DHS/DFCS and its Providers still must provide services to the person with a disability, as appropriate, to the maximum extent possible. If eligibility workers are unsure about whether a reasonable modification can or should be provided, they must consult with a supervisor at the time the request for reasonable modification is received or as soon as reasonably possible thereafter. If a supervisor agrees that a reasonable modification can and should be provided, the eligibility worker is required to provide the requested modification to the constituent. However, if the supervisor recommends that the request for reasonable modification be denied, the supervisor must submit the DHS/DFCS Reasonable Modifications (RM) and Communication Assistance (CA) Tracking Form and any supporting documentation with recommendations for review to the District ADA/Section 504 Coordinator. The District ADA/Section 504 Coordinator reviews the supervisor’s denial request and forwards the Reasonable Modification and Communication Assistance Request Tracking Form 102 (Attachment 3) to the State DHS/DFCS ADA/Section 504 Coordinator. For instructions on how to complete Form 101 and/or Form 102, please see Attachment 2. The State DHS/DFCS Civil Rights and ADA/Section 504 Coordinator will review the complaint involving request for reasonable modification and the recommendation for denial of the request and will consult with the appropriate DHS/DFCS OFI Program Unit Manager and/or OFI Deputy Commissioner. Only the DHS/DFCS Division Director or his/her designee has the authority to deny, in whole or in part, reasonable modification requests or otherwise refuse requests for reasonable modifications. After the final agency decision on the request for reasonable modifications is made, the DHS/DFCS District ADA/Section 504 Coordinator is responsible for drafting and providing a written decision to the constituent, after consultation with the State DHS/DFCS ADA/Section 504 Coordinator.

DHS/DFCS and its Providers must ensure communications with applicants, participants, members of the public and companions with disabilities are as effective as communications with others.

The key to communicating effectively is to consider the nature, length, complexity, and context of the communication and the constituent’s normal method(s) of communication. This may also involve verifying that the communication is understood, using multiple methods of explanation to the constituent with a disability.

Companion. In some situations, DHS/DFCS may communicate with a constituent’s companion with a disability. A companion is any family member, friend, or associate of a constituent seeking or receiving an entity’s goods or services who is an appropriate person with whom the entity should communicate. DHS/DFCS and its Providers must provide appropriate auxiliary aids and services when necessary to ensure effective communication with constituents with disabilities. This includes an obligation to provide effective communication to companions with disabilities. These auxiliary aids and services must be provided at no cost to the constituent and in a timely manner that protects the privacy and independence of constituents and their companions with a disability.

Auxiliary Aids and Services. Auxiliary aids and services refer to the ways to communicate with people who have communication disabilities (e.g., DHS/DFCS constituents with hearing, vision, and speech disabilities). Auxiliary aids and services include but are not limited to qualified sign language interpreters, telephone handset amplifiers, assistive listening devices, closed caption decoders, real time captioning, TTY/TTD relay services for Deaf and hard-of-hearing, screen reader software, Braille, large print materials, alternative keyboards for constituents who are blind and have low vision. Examples of auxiliary aids and services for people who are blind, have vision loss, or are DeafBlind might be: Providing a qualified reader, information in large print, Braille, or electronically for use with a computer screen-reading program, or an audio recording of printed information. Examples of auxiliary aids and services for people who are Deaf, have hearing loss, or are DeafBlind might be: Providing a qualified note taker, a qualified sign language interpreter, oral interpreter (non-language), cued-speech interpreter, or tactile interpreter; real-time captioning; or written materials. Examples of auxiliary aids and services for people who have speech disabilities might include: Providing a qualified speech-to-speech transliterator (a person trained to recognize unclear speech and repeat it clearly), especially if the person will be speaking at length, or just taking more time to communicate with someone who uses a communication board. Video remote interpreting (VRI) services also provide qualified interpreters. A public entity elects to provide qualified interpreters through VRI services, it must ensure that the computer, tablet or other device used complies with the technological requirements of the ADA at 28 C.F.R. § 35.160(d). Eligibility workers are required to provide application and renewal forms, system-generated individual and household communications and notices of decision (i.e. approvals, changes, terminations, and denials) and renewal notices in large print, Braille, audio format, or data format to qualified constituents with a disability upon request and as required by law. With respect to communication disabilities, state or local government agencies must give primary consideration to the constituent’s choice of auxiliary aid and service, unless it can demonstrate that another equally effective means of communication is available, or that the use of the means chosen would result in a fundamental alteration or a financial or administrative undue burden. [28 C.F.R. § 35.160(b)(2)]. If the choice expressed by the constituent with a disability would result in an undue burden or a fundamental alteration, the public entity still has an obligation to provide an alternative aid or service that provides effective communication if one is available. The decision that a particular aid or service would result in an undue burden or fundamental alteration must be made by the DHS/DFCS Division Director or his/her designee and must be accompanied by a written statement of the reasons for reaching that conclusion. Public accommodations (e.g. private community partner agencies) that provide DHS/DFCS services are encouraged to consult with the constituent with a disability to discuss what aid or service is appropriate. The goal is to provide an aid or service that will be effective, given the nature of what is being communicated and the constituent’s method of communicating. When an eligibility worker or other staff becomes aware that a constituent has a disability that substantially limits the constituent’s ability to see, hear or speak, the eligibility worker or staff must inquire as to the constituent’s potential need for auxiliary aids and services. If a constituent expresses a need for assistance related to a disability, or if the constituent has a disability that is documented in Gateway, eligibility workers who have access to Gateway are required to discuss the possible need for auxiliary aids and services with the constituent using the Gateway written prompts. If a constituent indicates that he or she does not wish to disclose or to discuss their disability, staff will not make further inquiries on these subjects. Constituents with disabilities may request an auxiliary aid or service by completing the Reasonable Modification and Communication Assistance Request Form (Form 101). Please refer to the Reasonable Modifications Section above for procedures handling documenting requests for assistance in Gateway.

Interpreters. DHS/DFCS and its Providers must assure that any interpreter used to communicate with a DHS/DFCS constituent with a disability is qualified to do so. This includes qualified interpreters (i.e. American Sign Language, Signed Exact English (SEE) interpreters, oral interpreters, tactile interpreters, and Computer Assisted Real-time Transcription (CART)). When a constituent who is Deaf or hard-of-hearing notifies staff that the interpreter provided is not qualified to interpret for that constituent, either DHS/DFCS or its Provider staff must arrange for a qualified interpreter service or other appropriate auxiliary aid and service, as required by law. DHS/DFCS and Provider staff are prohibited from requiring a constituent to bring a person to serve as the interpreter. Staff will not rely on an adult accompanying a constituent with a disability to interpret or facilitate communications except (a) in an emergency involving an imminent threat to the safety or welfare of an individual or the public where there is no interpreter available, or (b) where the constituent with a disability specifically requests that the accompanying adult interpret or facilitate communication, the accompanying adult agrees to provide such assistance, and reliance on that adult for such assistance is appropriate under the circumstances. Staff will not rely on a minor child to interpret or facilitate communications with a constituent, except in an emergency involving an imminent threat to the safety or welfare of an individual or the public where there is no interpreter available.

DHS/DFCS and its Providers must allow constituents with disabilities who use wheelchairs, mobility aids or other power-driven mobility devices (OPDMD) into all areas where the public is allowed to go, unless the entity can demonstrate that the particular type of device cannot be accommodated because of legitimate safety requirements. Such safety requirements must be based on actual risks, not on speculation or stereotypes about a particular class of devices or how constituents will operate them.

An OPDMD means any mobility device powered by batteries, fuel, or other engines – whether or not designed primarily for use by individuals with mobility disabilities – that is used by individuals with mobility disabilities for the purpose of locomotion.

Staff must consider these factors in determining whether to permit OPDMDs on their premises:

the type, size, weight, dimensions, and speed of the device;

the volume of pedestrian traffic (which may vary at different times of the day, week, month, or year);

the facility’s design and operational characteristics, such as its square footage, whether it is indoors or outdoors, the placement of stationary equipment, devices, or furniture, and whether it has storage space for the device if requested by the constituent;

whether legitimate safety standards can be established to permit the safe operation of the device; and

whether the use of the device creates a substantial risk of serious harm to the environment or natural or cultural resources or poses a conflict with Federal land management laws and regulations.

Communicate clearly to the public any OPDMD not permitted in an area where DHS/DFCS programs, services and activities are offered. Staff may not ask constituents using such devices about their disability but may ask for a credible assurance that the device is required because of a disability. If the constituent presents a valid, State-issued disability parking placard or card or a State-issued proof of disability, it must be accepted as credible assurance on its face. If the constituent does not have this documentation, but states verbally that the device is being used because of a mobility disability, that also must be accepted as credible assurance, unless the constituent is observed doing something that contradicts the assurance.

Under the ADA, a service animal is defined as a dog that has been individually trained to do work or perform tasks for a constituent with a disability. DHS/DFCS and its Providers must provide a constituent with a disability, who is accompanied by a service animal, an equal opportunity to participate in DHS/DFCS programs, services, and activities.

Staff may ask two questions in relation to a service animal:

Is the dog a service animal required because of a disability?

What work or task has the dog been trained to perform?

Service animals must be allowed in all areas of a facility where the public is allowed except where the dog’s presence would create a legitimate safety risk or would fundamentally alter the nature of a public entity’s services. Service animals may be excluded only if 1) the dog is out of control and the handler cannot or does not regain control; or 2) the dog is not housebroken. If a service animal is excluded, staff must allow constituents to enter the facility without the service animal.

A service animal must have a harness, leash or other tether, unless the handler is unable to use a tether because of a disability or the use of a tether would interfere with the service animal’s ability to safely perform its work or tasks. In these cases, the service animal must be under the handler’s control through voice commands, hand signals, or other effective means. If a service animal is excluded, the constituent with a disability must still be offered the opportunity to obtain goods, services, and accommodations without having the service animal on the premises.

Staff may not require constituents with disabilities to provide documentation, such as proof that the animal has been certified, trained, or licensed as a service animal, as a condition for entry. Service animals are not required to wear service animal vests or patches, or to use a specific type of harness.

Allergies and fear of dogs are not valid reasons for denying access or refusing service to people using service animals. When a person who is allergic to dog dander and a person who uses a service animal must spend time in the same room or facility, they both should be accommodated by assigning them, if possible, to different locations within the room or different rooms in the building. But, as with any reasonable modification, determination on how to address allegations involving allergies or other direct threat or safety concerns is done on a case-by-case basis.

Although not service animals, miniature horses have similar protections under the ADA. DHS/DFCS and its Providers must permit access where reasonable for miniature horses that are individually trained to do work or perform tasks for constituents with disabilities. Federal regulations set out four assessment factors to assist staff in determining whether miniature horses can be accommodated in their facility. The assessment factors are (1) whether the miniature horse is housebroken; (2) whether the miniature horse is under the owner’s control; (3) whether the facility can accommodate the miniature horse’s type, size, and weight; and (4) whether the miniature horse’s presence will not compromise legitimate safety requirements necessary for safe operation of the facility.

DHS/DFCS and its Providers must ensure program websites and online systems are accessible to constituents with disabilities. DHS/DFCS and its Providers should ensure that in-house staff and contractors responsible for web page and content development are properly trained. DHS/DFCS and its Providers must ensure that constituents who are disabled are able to request accessible information or services to the extent required by law. Information related to web page accessibility, including the current version of the Web Content Accessibility Guidelines (and associated checklists), can be found at www.w3c.org/WAI/Resources .

DHS/DFCS and its Providers must ensure constituents with disabilities are not excluded from programs and services because facilities are unusable or inaccessible to them. DHS/DFCS and its Providers must ensure that constituents with disabilities have access to programs and services under the same terms and conditions as constituents without disabilities. These entities must abide by the ADA Standards for Accessible Design.

DHS/DFCS and its Providers may impose legitimate safety requirements necessary for the safe operation of its services, programs, or activities. However, DHS/DFCS and its Providers must ensure that its safety requirements are based on real risks, not on speculation, stereotypes, or generalizations about constituents with disabilities.

The ADA does not require DHS/DFCS or its Providers to permit a constituent to participate in or benefit from the services, programs, or activities of DHS/DFCS when that constituent poses a direct threat to the health or safety of others (not to self).

Direct Threat means a significant risk to the health or safety of others that cannot be eliminated by a modification of policies, practices or procedures, or by the provision of auxiliary aids or services as provided in 28 C.F.R. § 35.139 (Title II) and 28 C.F.R. § 36.208 (Title III).

In determining whether a constituent poses a direct threat to the health or safety of others, DHS/DFCS and its Providers must make an individualized assessment, based on reasonable judgment that relies on current medical knowledge or on the best available objective evidence to ascertain: the nature, duration, and severity of the risk; the probability that the potential injury will actually occur; and whether reasonable modifications of policies, practices, or procedures or the provision of auxiliary aids or services will mitigate the risk.

The State agency, local agency, subrecipient and contractor are not required to modify its policies, practices, or procedures if the entity can demonstrate that making a reasonable modification due to a disability would fundamentally alter the nature of the service, program, or activity. If the modification requested would cause undue financial burden on the program or activity to the level that it would make continued operation of the program unfeasible, the modification need not be provided. However, denying a modification(s) under the fundamental alteration exception should not result in the denial of access to the program or other benefits or services.

The DFCS Division Director or his/her designee must make the decision that a particular aid or service would result in an undue burden or fundamental alteration to the service, program, or activity. The decision must include a written statement that details the reasons that support the determination. The State agency, local agency, sub recipients or contractors still must provide services to the maximum extent possible.

The integration of constituents with disabilities into the mainstream of society is a fundamental purpose of the ADA. DHS/DFCS and its Providers will administer its programs, services, and activities in the most integrated setting appropriate to the needs of qualified constituents with disabilities. This means providing services that avoid unnecessary separation or segregation of people with disabilities from the rest of the community to ensure equal opportunity or equally effective benefits and services.

For ADA training requirements, please refer to the DFCS Policy 3701 - Civil Rights .

All DHS/DFCS constituents and the public have a right to file a complaint of discrimination on the basis of race, color, national origin, age, sex, disability, or any other protected class, or for reprisal or retaliation for engaging in prior civil rights activity. For more information, please refer to the DFCS Civil Rights and ADA/Section 504 Complaint Process and the DFCS Civil Rights, ADA/Section 504 Complaint Form on the DFCS Nondiscrimination and Disability webpage at: DHS/DFCS.georgia.gov/adasection-504-and-civil-rights .

While the DFCS Division Director is responsible for the Division’s Civil Rights and ADA/Section 504 compliance, all DHS/DFCS staff administering DHS/DFCS programs, services, and/or activities are required to adhere to the DFCS Civil Rights policy.

The DFCS Civil Rights and ADA/Section 504 Coordinator is the official designee responsible for ensuring the Division’s compliance with civil rights laws and regulations, including Title VI, the ADA, and Section 504. The Coordinator’s responsibilities include, but are not limited to investigating civil rights complaints, ensuring DHS/DFCS constituent requests for reasonable modifications, and the provision of auxiliary aids and services (e.g., assisting DHS/DFCS staff with constituents with disabilities).

In coordination with the DFCS Civil Rights and ADA/Section 504 Coordinator, designated DFCS District ADA/Section 504 Coordinators are responsible for providing support to the Office of Family Independence relating to compliance with disability laws. DFCS Child Welfare Regional ADA/Section 504 Coordinators provide related ADA support for child welfare services (adoptions, foster care, and/or child abuse and neglect).

The DFCS Quality Assurance Unit is responsible for providing Civil Rights and ADA/Section 504 compliance activities for DFCS’ Office of Family Independence.

Staff must report concerns, instances, and complaints of noncompliance with civil rights policies to the DFCS Civil Rights and ADA/Section 504 Coordinator. For questions regarding Civil Rights and ADA/Section 504 policies and procedures, contact the DFCS Civil Rights and ADA/Section 504 Coordinator at civilrights-ADAcoordinator@dhs.ga.gov .

This policy replaces all other DFCS policies on the ADA, [PC28.1][ER28.2]including but not limited to, all prior DFCS Methods of Administration policies; DFCS Food Stamp Policy 3025 (General Program Overview: Americans with Disabilities Act (ADA) and Section 504); DFCS Medicaid Policy 2020 (General Medicaid Information: Americans with Disabilities Act (ADA) and Section 504); and DFCS TANF Policy 1004 (General Program Overview: Americans with Disabilities Act (ADA) and Section 504).

Attachment 1: DFCS District and State ADA/Section 504 Coordinator Duties Attachment 2: Reasonable Modification and Communication Assistance Request Tracking Form (Form 102) Attachment 3: ADA/RM Form 101 and 102 Instructions Attachment 4: ADA RM Form 101 and 102 County Tracking Log Attachment 5: US Department of Justice (DOJ) ADA Requirements: Effective Communication Attachment 6: DOJ ADA Title II Primer Attachment 7: DOJ Accessibility of State and Local Government Websites to People with Disabilities

Georgia Division of Family and Children Services Civil Rights Policy Manual Effective Date: January 1, 2026 Policy Title: Civil Rights Next Review: January 1, 2028 Policy Number: 3701 Previous Policy Number(s): FS Policy 3030, MA Policy 2025, TANF Policy 1003

It is the policy of the Georgia Department of Human Services (DHS), Division of Family and Children Services (DFCS) that DHS/DFCS comply with laws, regulations, and policies prohibiting unlawful discrimination on the basis of race, color, national origin, age, sex, disability, retaliation for prior civil rights activity, or any other protected class in the administration of DHS/DFCS programs, services, and activities.

This policy addresses the responsibility of DHS/DFCS and its subrecipients, contractors, grantees, agents, and providers of services (Providers) to comply with civil rights laws and regulations, including but not limited to, Title VI of the Civil Rights Act of 1964, Age Discrimination Act of 1975, Title IX of the Education Amendments of 1972, Title II of the Americans with Disabilities Act of 1990, and Section 504 of the Rehabilitation Act of 1973. This policy also addresses compliance with nondiscrimination provisions applicable to federally-assisted programs of the US Department of Health and Human Services (HHS) (e.g., Medicaid, TANF, Child Welfare) and the US Department of Agriculture (USDA) (e.g., Supplemental Nutrition Assistance Program (SNAP), Commodity Supplemental Food Program (CSFP), The Emergency Food Assistance Program (TEFAP)).

This policy replaces all prior DHS/DFCS civil rights provisions, policies, procedures, forms, or other documents that are inconsistent with or conflict with the provisions of this policy.

Civil rights provisions relating to DHS employment and sexual harassment matters are addressed in DHS OHR Policy 101 and DHS OHR Policy 102 , respectively.

This policy applies to all DHS/DFCS staff and its Providers, as required by law, contract, or agreement, who are involved with the administration of DHS/DFCS programs, services, and activities.

This is not an exhaustive list of all civil rights authorities that may be applicable to DHS/DFCS programs and Providers.

Title VI of the Civil Rights Act of 1964 ( 42 U.S.C. § 2000d et seq. ; 28 C.F.R. § 42.101 et seq. [Department of Justice (DOJ)]; 7 C.F.R. § 15.1 et seq. , 15.60 et seq. [USDA]; 45 C.F.R. § 80.1 et seq. [HHS]).

Section 504 of the Rehabilitation Act of 1973 ( 29 U.S.C. § 794 ; 28 C.F.R. § 42.501 et seq. [DOJ]; 7 C.F.R. § 15b et seq. [USDA]; 45 C.F.R. § 84.1 et seq. [HHS]).

Title II of the Americans with Disabilities Act of 1990, as amended ( 42 U.S.C. § 12131 et seq. ; 28 C.F.R. § 35.101 et seq. [DOJ]).

Title III of the Americans with Disabilities Act of 1990, as amended ( 42 U.S.C. § 12181 et seq. ; 42 U.S.C. § 12205a ; 28 C.F.R. § 36.101 et seq. [DOJ]) (as applicable).

Americans with Disabilities Act Amendment Act of 2008 (ADAAA) ( 42 U.S.C. § 12101 et seq. ; 28 C.F.R. § 35 [DOJ]).

Age Discrimination Act of 1975 ( 42 U.S.C. § 6101 et seq. ; 7 C.F.R. Part 15c [USDA]; 45 C.F.R. § 91.1 et seq. [HHS]).

Title IX of the Education Amendments of 1972 ( 20 U.S.C. § 1681 et seq. ; 28 C.F.R. § 54.100 et seq. [DOJ]; 34 C.F.R. § 106 et seq. [ED]; 7 C.F.R. Part 15a [USDA]; 45 C.F.R. § 86.1 et seq. [HHS]).

Indian Child Welfare Act of 1978 ( 25 U.S.C. § 1901 et seq. ; 25 C.F.R. § 23.101 et seq. ).

The Food and Nutrition Act of 2008, as amended, Supplemental Nutrition Assistance Program (SNAP), formerly the Food Stamp Program ( 7 U.S.C. § 2011 et seq. ; 7 C.F.R. § 271 , 272 , 273 , 276 [USDA]).

Section 11(c) of the Food and Nutrition Act of 2008, as amended ( 7 U.S.C. § 2020(c) ).

Food and Nutrition Service (FNS) Nondiscrimination Compliance, ( 7 C.F.R. § 247.4(c)(6) , 251.10(c),(e)(3) , 272.4 , 272.6 [USDA]).

FNS Instruction 113-1 : Civil Rights Compliance and Enforcement – Nutrition Programs and Activities.

Multiethnic Placement Act of 1994 ( 42 U.S.C. § 1996b , 45 C.F.R. § 1355.38 ) [HHS].

Executive Order (EO) 14224, "Designating English as the Official Language of the United States of America." Federal Register, vol. 90, no. 43, 6 Mar. 2025, pp. 11363–11364.

O.C.G.A. §§ 30-3-1 et seq.

O.C.G.A. §§ 30-4-1 et seq.

Civil Rights Assurances:

45 C.F.R. § 80.4(b) [HHS]

7 C.F.R. § 272.2(b) [SNAP]

7 C.F.R § 247.4(c)(6) [USDA/CSFP]

7 C.F.R. § 251.14(b) [USDA/TEFAP]

7 C.F.R, § 250.5 [USDA/CSFP, USDA/TEFAP].

The terms in this policy shall mean the following unless the context otherwise requires:

“ADA” means Title II of the Americans with Disabilities Act of 1990, a civil rights law which prohibits discrimination on the basis of disability in state and local government programs, services, and activities.

“Auxiliary aids and services” mean devices or services that enable effective communication for persons with disabilities including, but not limited to, qualified interpreters, notetakers, real-time computer-aided transcription services, assistive listening devices, brailled materials and displays, large print materials, qualified readers, taped texts, audio recordings, acquisition or modification of equipment or services, and other similar services and actions.

“Companion” means any family member, friend, or associate of a person seeking or receiving DHS/DFCS services who is an appropriate person with whom DHS/DFCS should communicate.

“Disability” means a physical or mental impairment that substantially limits one or more of an individual’s major life activities. The term also includes having a history or record of such an impairment or being regarded as having such an impairment even if an individual does not actually have such an impairment.

“Discrimination” means the act (or action), whether intentional or unintentional, through which an individual, solely because of race, color, age, sex, disability, national origin or any other protected class, has been otherwise subjected to unequal treatment under any program, service, or activity receiving federal financial assistance.

“LEP” or “limited English proficiency” means an inability to speak English as a primary language or a limited ability to read, speak, write, or understand English.

“Major life activities” include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, reading, concentrating, learning, thinking, communicating, as well as the operation of bodily functions, such as neurological and brain functions.

“National origin” includes, but is not limited to, a person’s or their ancestors' place of origin (such as country or world region) or a person’s manifestation of the physical, cultural, or linguistic characteristics of a national origin group.

“Reasonable modification” means a change in a policy, practice, or procedure that is made to offer equal access to a public entity’s programs, services, or activities for a person with a disability. A modification that fundamentally alters the nature of a service program, or activity; or a modification that results in an undue financial or administrative burden (applies only to recipients of federal financial assistance) is not a reasonable modification.

“Section 504 of the Rehabilitation Act of 1973” or “Section 504” prohibits discrimination based on disability against otherwise qualified individuals on the basis of disability in all programs, services, and activities receiving federal financial assistance.

“Sensory Impairment” or “SI” means deafness, blindness, and anything that affects one of the senses such as sight, hearing, smell, touch, taste and spatial awareness.

"Title VI of the Civil Rights Act of 1964” or “Title VI” means a federal law that prohibits discrimination on the basis of race, color, or national origin under programs or activities receiving federal financial assistance.

The following measures are required by DHS/DFCS to prevent discrimination and ensure equal access to DHS/DFCS programs and services:

Nondiscrimination in DHS/DFCS Programs, Services and Activities DHS/DFCS and its Providers are prohibited from unlawfully discriminating in the administration of DHS/DFCS programs, services, and activities on the basis of race, color, age, sex, disability, national origin, or any other program-specific protected class. DHS/DFCS and its Providers are also prohibited from engaging in reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by a federal agency. Click here to access DFCS’ Notice of ADA/Section 504 Rights and the joint USDA and HHS Notice of Nondiscrimination.

Right to File a Civil Rights, ADA/Section 504 Complaint Constituents who allege unlawful discrimination have the right to file a civil rights complaint, which includes complaints about decisions made regarding requests for reasonable modifications for constituents with disabilities and requests for language assistance services (e.g., interpreters and translated materials) for constituents with limited English proficiency (LEP) or sensory impairments (SI). All written or verbal complaints alleging discrimination on the basis of race, color, age, sex, disability, national origin, retaliation for engaging in prior civil rights activity in DHS/DFCS programs, activities or services, or any other program-specific protected class, are processed in accordance with the DFCS Civil Rights, ADA/Section 504 Complaint Process . DHS/DFCS and its Providers must forward all discrimination complaints to the DFCS Civil Rights and ADA/Section 504 Coordinator as required by DFCS’ Complaint Process. For more information about the DFCS Civil Rights, ADA/Section 504 complaint process or to access a complaint form, visit dfcs.georgia.gov/adasection-504-and-civil-rights .

Right to Request Reasonable Modifications and Free Communication Assistance Reasonable Modifications Reasonable modifications afford an individual with a disability an equal opportunity to participate in all DHS/DFCS programs and receive all benefits and services for which that individual is eligible. DHS/DFCS must make reasonable modifications in policies, practices, or procedures when necessary to avoid discrimination on the basis of disability, unless it is demonstrated that making the modification would fundamentally alter the nature of the service, program, or activity or result in undue financial and administrative burdens. For more information about the requirement to provide reasonable modifications to constituents with disabilities or to access a Reasonable Modification or Communication Assistance form, visit dfcs.georgia.gov/adasection-504-and-civil-rights . Auxiliary Aids and Services for Communication DHS/DFCS and its Providers must provide free auxiliary aids and services for DHS/DFCS constituents (and their companions) with communication disabilities (e.g., hearing, vision, and speech) to ensure equally effective communication in accordance with the ADA and Section 504. For more information about communication assistance for constituents with disabilities, visit dfcs.georgia.gov/adasection-504-and-civil-rights . Language Assistance Services for Communication DHS/DFCS and its Providers must provide free qualified interpreters and translated information in a timely manner when communicating with DHS/DFCS’ constituents with LEP. Constituents with LEP do not speak English as their primary language and have a limited ability to read, write, speak, and/or understand English. Constituents with LEP may be competent in English for certain types of communication (e.g., speaking or understanding), but still be LEP for other purposes (e.g., reading or writing). A constituent may also be considered LEP if he/she prefers to communicate with DHS/DFCS, either orally or in writing, in a language other than English. For more information about providing constituents access to language assistance services, refer to DHS LEP/SI Policy 2001 .

Public Notifications DHS/DFCS and its Providers must inform applicants, participants, and potentially eligible persons of program availability, program rights and responsibilities, their protection against discrimination, and the procedure for filing a discrimination complaint. Additionally, DHS/DFCS and its Providers must provide effective notice to constituents with LEP of the availability of language assistance services (e.g., interpreters and translated information) in a language that they can understand . Similarly, DHS/DFCS and its Providers must notify constituents with disabilities of the availability of free auxiliary aids and services and reasonable modifications, including how to request each in a format that they can understand. Refer to DHS LEP/SI Policy 2001 for more information about public notices for persons with LEP. For more information or to obtain a copy of public notices for constituents with disabilities, visit dfcs.georgia.gov/adasection-504-and-civil-rights . For HHS Programs: DHS/DFCS and its Providers must provide a nondiscrimination statement to participants, beneficiaries, enrollees, and applicants of its programs and activities, and members of the public. The nondiscrimination statement must be at a conspicuous location on the DHS/DFCS website and in a clear and prominent physical location, where it is reasonable to expect constituents seeking service from the HHS program or activity to be able to read or hear the notice (45 C.F.R. § 92.10). For an electronic version of the nondiscrimination statement, visit dfcs.georgia.gov/adasection-504-and-civil-rights . For USDA Programs : The appropriate USDA Nondiscrimination Statement must appear in all information materials and sources, including web sites, used by DHS/DFCS and its Providers to inform the public about FNS programs (FNS Instruction 113-1, Section IX). For an electronic version of the USDA Nondiscrimination Statement, visit dfcs.georgia.gov/adasection-504-and-civil-rights or www.fns.usda.gov/cr/fns-nondiscrimination-statement . Similarly, the USDA issued directives on posting the appropriate And Justice for All (AJFA) poster. Form AD-475-A corresponds to the AJFA poster that is applicable to the Commodity Supplemental Food Program (CSFP) and The Emergency Food Assistance Program (TEFAP). Form AD-475-B corresponds to the AJFA poster that is applicable to SNAP. AJFA posters must be prominently displayed in all offices where there is a USDA presence and where constituents can view them. Please refer to FNS Instruction 113-1 , Section IX, Appendices A and C and USDA Departmental Regulation 4300-003 – Equal Opportunity Public Notification Policy or successive FNS instructions. To obtain an AJFA poster, contact the DFCS Food and Nutrition Unit Director.

Civil Rights and ADA/Section 504 Training Civil rights training is required for all DHS/DFCS and Provider staff involved in administering or delivering DHS/DFCS programs, activities, and services. All DHS/DFCS and Provider staff are required to complete the civil rights training, ADA/Section 504 training, and Customer Service and Communication training within 30 days of the date of hire and annually thereafter. Office of Family Independence and Child Welfare staff may be required to complete additional training specific to the operation of their respective programs, services, and systems. Training for DHS/DFCS staff is available on the DHS IOTIS website. Additional Training Requirements for USDA Programs : Training is required so that staff involved at all levels of the administration of programs that receive federal financial assistance comply with laws, regulations, procedures, and directives related to civil rights. Staff responsible for reviewing civil rights compliance must receive training to assist them in performing their compliance review responsibilities. The FNS Regional Civil Rights Officer may provide civil rights training or technical assistance to DHS/DFCS state-level personnel. DHS/DFCS is responsible for training the appropriate state-level personnel, local DHS/DFCS office personnel, and its Providers, including “frontline staff.” “Frontline staff” who interact with program applicants or participants, and their supervisors, must receive civil rights training on an annual basis. “Frontline staff” also includes Providers. FNS Instruction 113-1, Section XI provides that civil rights training for USDA programs (e.g., SNAP, CSFP, TEFAP) must include, but is not limited to the following specific topics: collection and use of data, effective public notification systems, complaint procedures, compliance review techniques, resolution of noncompliance, requirements for reasonable modifications and auxiliary aids and services for constituents with disabilities, requirements for language assistance, conflict resolution, and customer service. Refer to the DHS IOTIS website to access Civil Rights and ADA/Section 504 training .

Race and Ethnicity Data Collection, Maintenance, and Reporting DHS/DFCS must ensure that the appropriate data is collected and maintained by its local agencies and its Providers when required by federal and state statutes, regulations or directives. This includes collection of race and ethnicity data in accordance with the U.S. Office of Management and Budget and each federal or state agency requirements. This data is to determine how effectively DHS/DFCS’ programs, activities, and services are reaching potentially eligible persons and beneficiaries, identify areas where additional outreach is needed, assist in the selection of locations for civil rights compliance reviews, and complete reports as required. Each federal agency has collection, maintenance, and reporting requirements. Refer to policies and procedures applicable to a specific program for its data collection requirements. DHS/DFCS programs, services and activities funded by the USDA (e.g., SNAP, CSFP and TEFAP) must follow the applicable “Data Collection and Reporting” requirements in FNS Instruction 113-1 , Section XII and in Appendices A and C, or successive FNS instructions.

Collection of Citizenship, Immigration Status, and Social Security Numbers DHS/DFCS programs are required to comply with applicable federal and state provisions regarding noncitizen eligibility and the collection of this data. However, DHS/DFCS programs must ensure that the collection and verification of citizenship status, immigration status or social security numbers, when required by federal statutes and regulations, does not result in an access barrier or unlawful discrimination in DHS/DFCS programs, services or activities. Constituents who are eligible to participate in a DHS/DFCS program must not be deterred or denied from applying for the program because a non-applicant household member has not disclosed his or her citizenship, immigration status or Social Security number. For USDA Programs : DHS/DFCS shall not request an applicant to provide citizenship status, immigration status, nor a social security number for CSFP and TEFAP eligibility. For SNAP eligibility, DHS/DFCS or its Providers shall not engage in the following: 1) Require information about the citizenship or immigration status of an individual who is not applying for SNAP; 2) Deny SNAP to household members applying for SNAP because a non-applicant household member fails to disclose citizenship status, immigration status, or a social security number; or 3) Attempt to establish or verify immigration status through means other than the procedures outlined in the SNAP Guidance on Non-Citizen Eligibility. DHS/DFCS has primary responsibility to determine the status of non-citizens applying for federal benefits. For additional information, refer to USDA FNS SNAP Guidance on Non-Citizen Eligibility .

Evaluating Civil Rights Compliance/Resolution of Noncompliance DHS/DFCS program staff shall monitor all civil rights criteria captured within each program’s management evaluations, quality assurance reviews, compliance reports, and civil rights reviews of its local agencies and its Providers and ensure that noncompliance issues are resolved in accordance with applicable federal guidelines. Staff must report concerns and instances of noncompliance with civil rights policies to the DFCS Civil Rights and ADA/Section 504 Coordinator . The DFCS Civil Rights and ADA/Section 504 Coordinator and program staff shall resolve noncompliance matters in a timely manner. For USDA Programs: Refer to FNS Instruction 113-1 , Sections XIII and XIV and Appendix A and Appendix C or successive FNS instructions. DHS/DFCS program staff performing compliance reviews must notify the DHS/DFCS local agency or Provider, in writing, of the findings and any requirements or recommendations upon the completion of the review. Noncompliance is a factual finding that a civil rights requirement, as provided by law, regulation, policy, instruction, or guidelines, is not being adhered to by DHS/DFCS or its Providers. The effective date of a finding of noncompliance is the date a written notice of noncompliance is provided to the entity under review. All DHS/DFCS programs must cooperate with the DFCS Civil Rights and ADA/Section 504 Coordinator and the DHS LEP/SI Program Manager (for LEP only) to resolve findings of noncompliance or concerns within 60 days of receipt of written notice of the findings or concerns. Additionally, DHS/DFCS must resolve instances of noncompliance in USDA programs in accordance with FNS Instruction 113-1 , Section XIV, or successive FNS instructions. The DFCS Civil Rights and ADA/Section 504 Coordinator must submit a report of Findings of Noncompliance, along with appropriate documentation to the FNS Regional Civil Rights Officer if the findings of noncompliance in a USDA program are not resolved within 60 days of the effective date.

Assurance of Nondiscrimination Language in Contracts and Agreements DHS/DFCS and its Providers must incorporate the appropriate assurance of nondiscrimination language in its agreements and contracts with subrecipients and contractors. Attachment A – USDA and HHS Assurances of Nondiscrimination contains samples of the current assurance language for USDA and HHS programs. Refer to FNS Instruction 113-1 - Civil Rights Compliance and Enforcement – Nutrition Programs and Activities, Section X, Appendices A and C or successive instructions or guidance for additional information regarding assurances of nondiscrimination in USDA programs.

Confidentiality DHS/DFCS is prohibited from disclosing Personally Identifiable Information (PII) or Protected Health Information (PHI) to unauthorized individuals. Therefore, DHS/DFCS will not disclose or allow access to complainant’s PII or PHI without the appropriate authorization. In situations where a companion or other individual requests a reasonable modification or communication assistance on behalf of an individual with a disability, DHS/DFCS will contact the individual with the disability or authorized representative to clarify the request.

The following is a non-exhaustive list of resources to civil rights and ADA/Section 504 notices, policies, manuals, forms, and other tools applicable to DHS/DFCS programs and Providers. Generally, policies and procedures are available on the DHS Policy and Manual Management System ( PAMMS ).

Policies, Manuals, and Forms (applies to all DHS/DFCS programs, activities, and services) DFCS Policy 3601 - Americans with Disabilities Act and Section 504 of the Rehabilitation Act DHS Policy 2001 - DHS Limited English Proficiency/Sensory Impairment (LEP/SI) Policy DHS Manual 2001 - Access Plan for Constituents with Limited English Proficiency (LEP) and Sensory Impairments (SI) DFCS Civil Rights and ADA/Section 504 Complaint Process (available in English and Spanish ) DFCS Civil Rights, ADA/Section 504 Complaint Form 724 (available in English and Spanish ) DFCS Reasonable Modification and Communication Assistance Request Form for Persons with Disabilities Form 101 (available in English , English large print , Spanish , Spanish large print ) ADA Reasonable Modification Form 101 and 102 Instructions DFCS Reasonable Modifications (RM) and Communication Assistance (CA) Tracking Form 102 ADA Reasonable Modification Form 101 and 102 Manual Tracking Log

Training DHS 1100 - Civil Rights and LEP/SI (applies to all DFCS and OFI Community Partners, required annually and within 30-days of hire) Training materials available on DHS IOTIS training site

Required Signage and Posters DFCS “Notice of ADA/Section 504 Rights” DFCS U.S. Department of Agriculture’s and U.S. Department of Health and Human Services’ Joint Nondiscrimination Statement Georgia Department of Human Services Notice of Free Interpretation Services “AND JUSTICE FOR ALL” Posters TEFAP and CSFP (FNS Form AD-475A) SNAP (FNS Form AD-475B) DFCS programs, services and activities funded by the USDA (e.g., SNAP) must follow applicable “Public Notification” requirements (e.g., FNS Instruction 113-1).

DHS/DFCS Webpage Links DFCS Nondiscrimination and Disability ( dfcs.georgia.gov/adasection-504-and-civil-rights ) ADA/Section 504 documents and forms ( dfcs.georgia.gov/adasection-504-and-civil-rights ) LEP/SI ( dhs.georgia.gov/organization/about/language-access )

Office of Family Independence (OFI) Policies, procedures, and forms (applies to all OFI programs) DFCS’ “Duties of the Office of Family Independence District ADA/Section 504 Coordinators” (See POL 3601 Americans with Disabilities Act and Section 504 of the Rehabilitation Act-Attachment 1) DFCS OFI “ADA/Section 504 District Coordinator List” DFCS “Quality Assurance Unit’s Plan for Periodic Random Sampling of Fair Hearing Requests and ADA/Section 504 DFCS County” (DFCS Management Evaluation (ME) Plan) DFCS “County Department Civil Rights/ADA Reasonable Modifications Compliance Review Guide” (Form 723) SNAP Policies Policy 3025 Americans with Disabilities Act (ADA) and Section 504 Policy 3030 Civil Rights Medicaid Policies Policy 2020 Americans with Disabilities Act (ADA) and Section 504 Policy 2025 Civil Rights TANF Policies Policy 1003 Civil Rights Policy 1004 Americans with Disabilities Act (ADA) and Section 504 Energy Assistance Program (LIHEAP) Policies Policy 800 Americans with Disabilities Act and Section 504 Community Services Block Grant (CSBG) Program Policies Policy 800 Americans with Disabilities Act (ADA) and Section 504 Training (Available on DHS IOTIS training site): DHS 1100 - Civil Rights and LEP/SI (All DFCS and Gateway Community Partners, required annually and within 30-days of hire) ADA 204 - ADA Section 504 Training (OFI and Gateway Community Partners only) WEX 242: ADA Training Updates (OFI only, Gateway training) WEX 243: CR 675021 Civil Rights Updates (OFI only, Gateway training) ADA/Section 504 DFCS District Coordinator Training (OFI only) DHS 3000: Customer Service and Communication R.H. et al. v. Rawlings et al., CAFN: 1:17-CV-01434-TWT (N.D. Ga. 2019) (Consent Order filed on June 4, 2019)

Child Welfare Policies, procedures, and forms (applies to all child welfare programs) Policy 1.4 Non-Discriminatory Child Welfare Practices Policy 1.5 Americans with Disabilities Act (ADA)/Section 504 and Reasonable Modifications Policy 1.6 Indian Child Welfare Act (ICWA) and Transfer of Responsibility for Placement and Care to a Tribal Agency Policy 1.16 Civil Rights Complaint Process DFCS Child Welfare “ADA/Section 504 Regional Coordinator List” Foster care and adoption Policy 14.11 Individualized Assessment Individualized Assessment Tool for Prospective and Existing Caregivers Training (Available on DHS IOTIS training site): DHS 1100 - Civil Rights and LEP/SI (All DFCS, required annually and within 30-days of hire) OCP 833 – ADA/504 Individualized Assessment ADA/Section 504 DFCS Regional Coordinator Training –“WEB 153: Regional FC/Ado ADA Coordinator Training” (Foster care & adoption) OCP 777 - Indian Child Welfare Act (ICWA) OCP 131 – Multi-Ethnic Placement Act (MEPA)/Inter-Ethnic Adoption Provisions Act (IEPA) ADA 205 - Part 2: Civil Rights Protections for Individuals with Opioid Use Disorder

While the DFCS Division Director is responsible for the Division’s Civil Rights and ADA/Section 504 compliance, all DHS/DFCS staff administering DHS/DFCS programs, services, and/or activities are required to adhere to the DFCS’ Civil Rights policy.

The DFCS Civil Rights and ADA/Section 504 Coordinator is the official designee responsible for ensuring the Division’s compliance with civil rights laws and regulations, including Title VI, the ADA, and Section 504. The Coordinator’s responsibilities include, but are not limited to investigating civil rights complaints, ensuring DHS/DFCS constituent requests for reasonable modifications, and the provision of auxiliary aids and services (e.g., assisting DHS/DFCS staff with constituents with disabilities). In coordination with the DFCS Civil Rights and ADA/Section 504 Coordinator, designated DFCS District ADA/Section 504 Coordinators are responsible for providing support to the Office of Family Independence relating to compliance with disability laws. DFCS Child Welfare Regional ADA/Section 504 Coordinators provide related ADA support for child welfare services (adoptions, foster care, and/or child abuse and neglect).

The DFCS Quality Assurance Unit is responsible for providing Civil Rights and ADA/Section 504 compliance activities for DFCS’ Office of Family Independence.

The DHS LEP/SI Program Manager is responsible for providing support to DHS/DFCS regarding matters involving DHS/DFCS constituents with LEP.

Staff must report concerns and instances of noncompliance with civil rights policies to the DFCS Civil Rights and ADA/Section 504 Coordinator. For questions regarding Civil Rights and ADA/Section 504 policies and procedures, contact the DFCS Civil Rights and ADA/Section 504 Coordinator .

This policy replaces all other DFCS policies on civil rights, including but not limited to, all prior DFCS Methods of Administration policies; DFCS Food Stamp Policy 3030 (General Program Overview: Civil Rights); DFCS Medicaid Policy 2025 (General Medicaid Information: Civil Rights); and DFCS TANF Policy 1003 (General Program Overview: Civil Rights).

The [contractor/subrecipient] agrees to comply with Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), Title IX of the Education Amendments of 1972 (20 U.S.C. 1681 et seq.), Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), the Age Discrimination Act of 1975 (42 U.S.C. 6101 et seq.), Section 11(c) of the Food and Nutrition Act of 2008, as amended (7 U.S.C. 2020), Title II and Title III of the Americans with Disabilities Act (ADA) of 1990 as amended by the ADA Amendments Act of 2008 (42 U.S.C. 12131-12189) as implemented by Department of Justice regulations at 28 CFR Parts 35 and 36, and all requirements imposed by the regulations issued by the Department of Agriculture to the effect that, no person in the United States shall, on the grounds of sex, race, color, age, disability, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subject to discrimination under SNAP. This includes program-specific requirements found at 7 CFR Part 15 et seq. and 7 CFR § 272.6.

This assurance is given in consideration of and for the purpose of obtaining any and all Federal assistance extended to the [contractor/subrecipient] under the authority of the Food and Nutrition Act of 2008, as amended. Federal financial assistance includes grants, and loans of Federal funds; reimbursable expenditures, grants, or donations of Federal property and interest in property; the detail of Federal personnel; the sale, lease of, or permission to use Federal property or interest in such property; the furnishing of services without consideration, or at a nominal consideration, or at a consideration that is reduced for the purpose of assisting the recipient or in recognition of the public interest to be served by such sale, lease, or furnishing of services to the recipient; or any improvements made with Federal financial assistance extended to the [contractor/subrecipient] by the USDA, State agency or local agency. This assistance also includes any Federal agreement, arrangement, or other contract that has as one of its purposes the provision of cash assistance for the purchase of food, cash assistance for purchase or rental of food service equipment or any other financial assistance extended in reliance on the representations and agreements made in this assurance.

By accepting this assurance, the [contractor/subrecipient] agrees to compile data, maintain records, and submit records and reports as required, to permit effective enforcement of nondiscrimination laws and permit authorized State agency and/or USDA personnel during hours of program operation to review and copy such records, books, and accounts, access such facilities and interview such personnel as needed to ascertain compliance with the nondiscrimination laws. If there are any violations of this assurance, USDA, FNS, shall have the right to seek judicial enforcement of this assurance. This assurance is binding on the [contractor/subrecipient] , its successors, transferees, and assignees as long as it receives assistance or retains possession of any assistance from USDA. The person or persons whose signatures appear below are authorized to sign this assurance on behalf of the [contractor/subrecipient] .

ASSURANCE OF COMPLIANCE WITH TITLE VI OF THE CIVIL RIGHTS ACT OF 1964, SECTION 504 OF THE REHABILITATION ACT OF 1973, TITLE IX OF THE EDUCATION AMENDMENTS OF 1972, THE AGE DISCRIMINATION ACT OF 1975, SECTION 1557 OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT, AND FEDERAL CONSCIENCE AND ANTI-DISCRIMINATION LAWS

*With respect to compliance with 45 C.F.R. Part 88, the signatory is providing assurance of compliance with such Part to the extent it is in effect during the term of the award. Consistent with applicable court orders, the version of Part 88 in effect as of December 2, 2019, is found at 76 Fed. Reg. 9,976-77 (February 23, 2011).

The Applicant provides this assurance in consideration of and for the purpose of obtaining Federal grants, loans, contracts, property, discounts or other Federal financial assistance from the U.S. Department of Health and Human Services.

THE APPLICANT HEREBY AGREES THAT IT WILL COMPLY WITH:

Title VI of the Civil Rights Act of 1964, as amended (codified at 42 U.S.C. § 2000d et seq.), and all requirements imposed by or pursuant to the Regulation of the Department of Health and Human Services (45 C.F.R. Part 80), to the end that, in accordance with Title VI of that Act and the Regulation, no person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which the Applicant receives Federal financial assistance from the Department.

Section 504 of the Rehabilitation Act of 1973, as amended (codified at 29 U.S.C. § 794), and all requirements imposed by or pursuant to the Regulation of the Department of Health and Human Services (45 C.F.R. Part 84), to the end that, in accordance with Section 504 of that Act and the Regulation, no otherwise qualified individual with a disability in the United States shall, solely by reason of her or his disability, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity for which the Applicant receives Federal financial assistance from the Department.

Title IX of the Education Amendments of 1972, as amended (codified at 20 U.S.C. § 1681 et seq.), and all requirements imposed by or pursuant to the Regulation of the Department of Health and Human Services (45 C.F.R. Part 86), to the end that, in accordance with Title IX and the Regulation, no person in the United States shall, on the basis of sex, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any education program or activity for which the Applicant receives Federal financial assistance from the Department.

The Age Discrimination Act of 1975, as amended (codified at 42 U.S.C. § 6101 et seq.), and all requirements imposed by or pursuant to the Regulation of the Department of Health and Human Services (45 C.F.R. Part 91), to the end that, in accordance with the Act and the Regulation, no person in the United States shall, on the basis of age, be denied the benefits of, be excluded from participation in, or be subjected to discrimination under any program or activity for which the Applicant receives Federal financial assistance from the Department.

Section 1557 of the Patient Protection and Affordable Care Act, as amended (codified at 42 U.S.C. § 18116), and all requirements imposed by or pursuant to the Regulation of the Department of Health and Human Services (45 CFR Part 92), to the end that, in accordance with Section 1557 and the Regulation, no person in the United States shall, on the ground of race, color, national origin, sex, age, or disability be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any health program or activity for which the Applicant receives Federal financial assistance from the Department.

As applicable, the Church Amendments, as amended (codified at 42 U.S.C. § 300a-7), the Coats-Snowe Amendment (codified at 42 U.S.C. § 238n), the Weldon Amendment (e.g., Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2019, Div. B., sec. 507(d), Pub. L. No. 115-245, 132 Stat. 2981, 3118 (Sept. 28, 2018), as extended by the Continuing Appropriations Act, 2020, and Health Extenders Act of 2019, Pub. L. No. 116-59, Div. A., sec. 101(8), 133 Stat. 1093, 1094 (Sept. 27, 2019)), Section 1553 of the Patient Protection and Affordable Care Act, as amended (codified at 42 U.S.C. § 18113), and Section 1303(b)(4) of the Patient Protection and Affordable Care Act, as amended (codified at 42 U.S.C. § 18023(b)(4)), and other Federal conscience and anti-discrimination laws, including but not limited to those listed at www.hhs.gov/conscience/conscience-protections , and all requirements imposed by or pursuant to the Regulation of the Department of Health and Human Services (45 C.F.R. Part 88), to the end that the rights of conscience are protected and associated discrimination and coercion are prohibited, in any program or activity for which the Applicant receives Federal financial assistance or other Federal funds from the Department for which the Federal conscience and anti-discrimination laws and 45 C.F.R. Part 88 apply.

The Applicant agrees that compliance with this assurance constitutes a condition of continued receipt of Federal financial assistance, and that it is binding upon the Applicant, its successors, transferees and assignees for the period during which such assistance is provided. If any real property or structure thereon is provided or improved with the aid of Federal financial assistance extended to the Applicant by the Department, this assurance shall obligate the Applicant, or in the case of any transfer of such property, any transferee, for the period during which the real property or structure is used for a purpose for which the Federal financial assistance is extended or for another purpose involving the provision of similar services or benefits. If any personal property is so provided, this assurance shall obligate the Applicant for the period during which it retains ownership or possession of the property. The Applicant further recognizes and agrees that the United States shall have the right to seek judicial enforcement of this assurance.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Application Processing Overview Effective Date: May 2026 Chapter: 2050 Policy Number: 2050 Previous MT Number(s): MT 78 Updated or Reviewed in MT: MT 79

The Medical Assistance application process begins with the request for health coverage and ends with notification to the Assistance Unit (AU) of the eligibility status.

An inquiry regarding public assistance programs can be made at any time, either in-person, by mail, telephone, fax, secure email, or at another designated agency. Information regarding public assistance programs must be provided to any individual without requiring that an application be filed.

An application must be provided to anyone upon request .

An application may be requested in person, by mail, telephone, fax, secure e-mail, or at any designated agency.

The A/R may apply for Medical Assistance at numerous locations throughout the State. These include the local county DFCS office, Social Security Administration, health departments, and some hospitals and nursing homes. The A/R may apply online at gateway.ga.gov/ . Applications are also available at local Right from the Start Medical (RSM) Assistance Group offices. The A/R can use the Georgia Department of Community Health website ( dch.georgia.gov ) to locate an application.

Anyone may apply for Medical Assistance benefits, including the following individuals:

the individual requesting assistance

an authorized representative (AREP) acting on behalf of the applicant. The AREP can be a relative, friend, guardian, or any person in a position to know the applicant’s circumstances. An elected AREP may have verbal or written designation. If the designation is written, the applicant’s signature is required.

the parent, specified relative or individual who provides/provided care and control of a child or deceased individual

an individual acting on behalf of an AU, including a representative of a private law firm or cost recovery company

a child requesting assistance for himself/herself

a Medicaid provider, via Newborn Eligibility Certification Form or via the web portal. DMA Form 550 is no longer used. DMA Form 551 is used for twins only.

The applicant/recipient (A/R) is the primary source of information for him or herself. The A/R may authorize an AREP to apply and provide information on his or her behalf. An elected AREP may have verbal or written designation. If the designation is written, the applicant’s signature is required. If the designation is verbal, it must be documented. If information provided by the AREP is questionable or unclear, attempt to contact th A/R for clarification. This may be accomplished either by telephone, mail, or in-person.

A face-to-face interview is NOT a requirement of any Medicaid Class of Assistance (COA).

The A/R may withdraw, at any time, authorization of an AREP to act on his or her behalf. This request can be given verbally or in writing. If the request is given verbally, it must be documented. If the request is written, the applicant’s signature is required.

An application may be filed on behalf of a deceased individual. Refer to Section 2068 - Special Considerations .

A complete application consists of a signed (either written or electronic such as via Gateway) application submitted with a name and information adequate to contact the applicant or AREP. A typed name on the signature line of a paper application is not acceptable.

It is NOT necessary for the applicant to complete all questions, as missing or incomplete information may be obtained by telephone, mail, fax, secure email, or in person. See Section 2060 - ABD Medicaid Application Processing and Section 2065 - Family Medical Assistance Application Processing for more program specific instructions.

An application received from GA Access which has been assessed as potentially eligible for Medical Assistance should be processed based on the information provided in the application. Do not request additional or duplicate information that has already been obtained by GA Access.

Assist the AU as needed to complete the application form.

The application form may be completed by the applicant, an AREP, or an agency representative. An application must be accepted without prior screening or interview.

An individual has the right to file an application on the day of the initial request for benefits. The agency will not refuse anyone the right to same day filing. The agency must inform the individual of the right to file an application on the same day she or he or his or her AREP contacts the agency in person, by telephone, mail, fax or secure email, expressing interest in obtaining assistance.

If an individual requests an application by mail, the right to same day filing is met if the application is mailed to the individual on the same day she or he makes the request to the agency.

“Right to Same Day Filing” affects the following:

beginning date for processing standard

determination of which three prior months may be considered for eligibility

The date of application is the date the application form is received by the county DFCS office, whether in-person, or by mail. When received via internet or fax, the date of application is the date the form was transmitted.

The application date is the day an application is received by a health department, disproportionate share hospital, public hospital or a federally funded, 330 health center, regardless of when the application is forwarded to the county DFCS office for processing.

An application must be registered within 24 hours of receipt by the agency.

Eligibility for Medical Assistance must be determined under all COAs before an application is denied. Refer to Section 2052 - Continuing Medicaid Determination (CMD) .

Eligibility for Medicaid coverage for the three months prior to the month of application must be considered for every Medical Assistance application filed.

Completion of the application process is defined as notification to the applicant of the approval or denial of Medical Assistance benefits.

An individual may withdraw an application for Medical Assistance at any time during the application process. A withdrawn application must be registered and denied. The applicant must be notified of the disposition of the withdrawn application.

Refer to Section 2011 - Health Information Portability and Accountability Act for information regarding privacy of health information.

If an individual receives Medical Assistance, and it is determined that documents are inconsistent with pre-existing information, are counterfeit or altered, the Division of Family and Children Services shall investigate for potential fraud and abuse and refer to Georgia Department of Community Health, Office of Inspector General:

By phone: in Metro Atlanta (404)463-7590, and statewide at (1-800-533-0686);

By email: medicaid.oig@dch.ga.gov ;

By mail: Department of Community Health, OIG PI Section, 2 Martin Luther King Jr Drive SE, 19 th Floor, East Tower, Atlanta, GA 30334; or

By internet: dch.georgia.gov/report-medicaidpeachcare-kids-fraud .

Refer to Section 2060 - ABD Medicaid Application Processing and Section 2065 - Family Medical Assistance Application Processing .

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Verification Effective Date: September 2024 Chapter: 2050 Policy Number: 2051 Previous MT Number(s): MT 69 Updated or Reviewed in MT: MT-73

Verification is the use of electronic data sources/computer matches, related active program(s), client statements, documents, collateral contacts with a third party, home visits, computer matches and documentation which confirm the accuracy of statements and information.

This verification policy applies at the following times:

application

renewals

interim changes

An assistance unit (AU) may provide verification using any of the following methods:

via mail

secure e-mail

in person

by facsimile or other electronic device

through an authorized representative (AREP)

by upload through Gateway or Document Imaging System (DIS) self-service kiosk

through a Community Partner agency

The agency may not require the AU to present verification in person.

Eligibility determinations must be based, to the maximum extent possible, on self-attestation of income that is verified by information from electronic data sources. When information from electronic data sources is consistent with an individual’s attestation of income, the income is considered verified.

Self-attestation may be accepted from the following:

The applicant

An adult in the applicant’s household

An authorized representative (AREP)

Someone acting responsibly for the individual (if the individual is a minor or incapacitated)

If verification is received by another program (e.g. SNAP or TANF), the verification should be used for Medical Assistance as well.

If there is a mismatch of information between what is provided to the agency by an A/R and the available electronic data sources, the EW must determine which source is most reliable or if the A/R needs to provide additional verification.

If the A/R’s statement and electronic data sources are above the applicable income limit, no additional verification is required. Enter the income as A/R’s attestation.

If both sources are at or below the applicable income limit, no additional verification is needed. Enter the income as A/R’s attestation but code as Other Acceptable Verification (OAV) and document.

If electronic source is above the applicable income limit and client attestation is below the applicable income limit, request 3 rd party verification to verify income and deductions.

If the A/R attests to income over the applicable income limit and electronic data source has income below the applicable limit, take the A/R’s attestation.

Refer ineligible adults or child(ren) to the Federally Facilitated Marketplace (FFM).

If the A/R’s attestation of self-employment income exceeds all applicable income limits, no additional verification is required. Enter the self-employment as the A/R’s attestation.

Client statement is accepted as verification for all criteria of Family Medicaid except for the following:

resources (for non-MAGI COAs) Refer to Section 2301 - Family Medicaid Resources Overview

citizenship/immigration status/identity See Section 2215 - Citizenship/Immigration/Identity for complete policy regarding procedures for verifying citizenship/immigration status/identity.

medical bills used in determining eligibility for Medically Needy Medicaid

questionable information

MAGI Deductions. Refer to Section 2655 - Family Medicaid Deductions

Client statement is acceptable for income verification in Pregnant Women and Newborn COAs.

Client statement is accepted as verification for all Q-Track criteria in ABD Medicaid, except for citizenship/immigration status/identity, or when circumstances are questionable.

The eligibility worker must document that the client’s statement was accepted or the reason why the information was questionable, and the method chosen to verify the information. Annotation of client statement in the verification field is acceptable documentation that client statement is accepted as verification.

The following situations must be verified from the source.

Citizenship/immigration status/identity must be verified for all COAs. Refer to Section 2215 - Citizenship/Immigration/Identity for acceptable forms of verification. Verification of immigration status is not required if eligibility is determined using Emergency Medical Assistance (EMA) procedures.

If a pregnant woman is claiming multiple births, the number of fetuses is not required to be medically verified to increase the size of the budget group unless questionable. If questionable, document in case notes why verification is required. If verification is not returned, the pregnant woman would count as a BG of 2.

Resources must be verified for Family Medicaid Medically Needy if the total value of the resources is at or above 75% of the resource limit. Refer to Section 2301 - Family Medicaid Resources Overview .

Medical bills used to meet Medically Needy Spenddown.

Any questionable situation or information must be verified. Verification must be requested for any information provided by the applicant/recipient that conflicts with information known to the agency, or that is otherwise questionable. Document the reason that the information is conflicting and/or questionable.

For ABD Medicaid verification requirements, see the sections pertaining to the specific COA and the Income and Resource Chapters.

The applicant/recipient’s statement is acceptable as verification for all other Family Medicaid and Q-Track eligibility situations.

Verify information, if required, to determine eligibility as follows:

Utilize Data sources prior to requesting any verification that cannot be located through the data sources.

Determine if verification is available from agency sources prior to requesting verification from the AU.

Requests for verification may be made verbally but must also be made in writing. The request for verification is provided to the applicant/recipient and, if applicable, the AREP.

Verbally or orally inform the applicant/recipient of any contacts that will be made with the verification source by the agency.

Allow sufficient time for the applicant/recipient to obtain verification.

Allow additional time to provide verification if requested by the applicant/recipient and the request is made within the SOP.

If incomplete verification is returned, send another checklist specifying what is required; establish a new reasonable deadline for returning requested verification.

Consider verification received for one program to be received for all programs.

Accept the applicant/recipient’s oral or written statement as verification when allowed by policy.

Do not require verification if the applicant/recipient’s oral or written statement establishes ineligibility (e.g. c/s of self-employment exceeds all applicable income limits, then no additional verification is required).

All Medical Assistance cases (except QMB and P4HB COAs) that close for failing to return verification will be reinstated if all the verification is returned within 90 days of closure ; an application will not be required. Refer to Section 2706 - Medicaid Renewals .

Third party verification includes the following:

documents – legal agreements, contracts, bills, leases, medical or doctor’s statements, prescription receipts, check stubs, employer statements, social security cards, driver’s license, etc.

collateral contacts – an oral or written statement from a third party, contact with a social service agency, etc. A collateral contact alone is not sufficient for verification of income. Documentary evidence such as a signed statement or Form 809 must be received, with the collateral contact made to validate. For more information, please see Collateral Contacts section below.

home visits – visits made by DFCS personnel or other state, local, community or federal agencies to confirm the accuracy of statements and information.

documentation – staff recording of AU’s statements, information and observations.

Data sources/computer matches – Gateway interface with other federal, state and local computer systems to compare and provide data regarding AU recipients.

This list is not all-inclusive.

The AU has the primary responsibility for providing verification to support statements or to resolve questionable information. The AU should be given sufficient time to verify information. When the value of a vehicle is obtained through blue book/NADA etc. and the listed value puts the AU over the resource limit, the AU must be given the opportunity to produce evidence of the value of the vehicle from someone who would have the expertise to make that determination such as a dealership.

The agency is responsible for assisting applicants/recipients in obtaining verification when the applicant/recipient requests assistance. Refer to Section 2020 - Americans with Disability Act (ADA) and Section 504 .

The agency must accept reasonable verification.

When possible, documents are used as the primary source of verification. Documents provide written evidence of the AU’s statements. Documents or photocopies of documents are filed in the case record and/or scanned into the Document Imaging System (DIS) as proof of the AU’s circumstances. All documents scanned into DIS will be tagged, at a minimum, with the Client ID(s) of the individual(s) the document(s) pertain(s) to, the ID(s) of the case(s) impacted, and with the appropriate document “type” (e.g. pay stubs as Proof of Income).

A collateral contact is an oral or written confirmation of the AU’s circumstances by a non-AU member. The collateral contact may be made in person, over the telephone, or in writing.

A collateral contact alone is not sufficient for verification of income. Documentary evidence such as a signed statement or Form 809 must be received, with the collateral contact made to validate.

If a written statement is provided by the collateral contact, the statement must be signed by the individual who wrote the statement. The statement should be dated but, if not dated, DFCS must date stamp or record on the statement the date it is received. The telephone number and/or address or way to contact the collateral contact must be furnished. This information may be provided as a part of the written collateral statement or recorded in the case file.

If a collateral statement is unacceptable to the agency because it is not completed correctly or lacks the required information and the AU is cooperating with providing information, then the agency must offer assistance to the AU. The agency may ask the AU to provide another collateral contact or contact the collateral contact directly.

The agency may substitute a home visit or select an alternative form of verification if circumstances warrant.

The agency must make sure that the AU understands what information is needed from the collateral contact. The request for verification form should specify what information is needed and the preferred format.

When taking a collateral statement on the telephone or in person, document in the case file the name, address, or telephone number of the contact, the date of the contact and the collateral contact’s statements regarding the AU.

The agency may select a collateral contact if the AU fails to designate one or designates one who is unacceptable to the agency. Examples of acceptable collateral contacts include employers, landlords, neighbors, social service agencies, etc.

When speaking with a collateral contact, the agency must disclose only the information that is absolutely necessary to obtain the information being sought. Avoid disclosing the following information:

that the AU has applied for/is receiving benefits

information supplied by the AU

information that cannot be released to anyone, including the AU, as provided in Section 2010 - Confidentiality .

that the AU is suspected of any wrongdoing.

The intent of this policy is to minimize the disclosure of information. Refer to Section 2010 - Confidentiality and Section 2011 - Health Information Portability and Accountability Act .

Refer to Section 2001 - Computer Matches Overview , Section 2002 - Income and Eligibility Verification System (IEVS) and Section 2004 - Clearinghouse . These sections provide policy regarding verification of case information by computer matching.

If appropriate, prearranged home visits may be used as verification. DFCS employees may use home visits if any of the following situations occur:

Third party verification is insufficient to make a firm determination of eligibility.

Third party verification cannot be obtained and the AU’s statement is questionable.

A home visit cannot be made or used as verification solely because an AU fits the profile of an error-prone AU as determined by the agency.

Case files must be documented in accordance with the standard documentation requirements. Case notes, the Document Imaging System (DIS) and Gateway together are considered the case file. A written recording of the information and statements provided by the AU is considered verification. This is the AU’s statement of its circumstances. The agency may also request that the AU make a separate, written statement to verify and/or clarify a specific point of eligibility.

Verify AU information as provided by the policy found in the manual.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Continuing Medicaid Determination Effective Date: July 2023 Chapter: 2050 Policy Number: 2052 Previous MT Number(s): MT 69 Updated or Reviewed in MT: MT-70

Eligibility must be reviewed under all Medicaid Classes of Assistance (COAs) before denying a Medical Assistance application or an individual in a Medicaid Assistance Unit (AU), and prior to termination of ongoing Medicaid eligibility for an entire AU or individual in an AU. For individuals who have been terminated SSI, DFCS will redetermine their Medicaid eligibility prior to DCH terminating their Supplemental Security Income (SSI) Medicaid.

Do not deny or terminate Medicaid eligibility before completing a Continuing Medicaid Determination (CMD) to consider eligibility under all other Medicaid COAs.

Complete a CMD on all SSI terminations that appear on DCH generated reports or transmitted via the Ex-Parte interface. Refer to 2750 DCH Reports-Ex Parte Lists for processing instructions.

If the MES becomes aware of A/Rs who, because of an SSI denial/termination, have been inappropriately receiving Medicaid under an Ex Parte COA, follow the same instruction found in 2750 DCH Reports-Ex Parte Lists .

Process the CMD according to which COA is most advantageous to the applicant/recipient (A/R).

Any Medicaid application form may be used to consider eligibility under any Medicaid COA. However, additional requirements may need to be satisfied depending on the specific COA under consideration. EXAMPLE: A Form 700 used for another ABD COA may require verification. Refer to 2060 ABD Medicaid Application Processing and 2065 Family Medicaid Application Processing for acceptable application forms.

For ABD Medicaid, consider eligibility under all COAs in the following order:

FBR COAs

LA-D/Medicaid CAP COAs

Q-Track COAs

AMN Q-Track COAs may be approved while the A/R is waiting to meet an ABD Medically Needy spenddown. Refer Medicare recipients to Georgia SHIP (formerly known as GeorgiaCares) for help with applying for Medicare Part D. See 2931 Medicare Part D and Low-Income Subsidy .

QI-1 recipients cannot be dually eligible ongoing with another COA with exception of AMN.

For Family Medicaid, consider eligibility in the following order:

Newborn

Pregnant Women

Parent/Caretaker

Other Family Medicaid COAs based on Parent/Caretaker eligibility criteria, i.e., TMA, 4MEx

Children Under 19

PeachCare for Kids®

Family Medicaid Medically Needy

Women’s Health Medicaid (WHM)

Pathways

Planning for Health Babies® If all verification requirements are met for Pregnant Women and/or Children Under 19, eligibility may be approved for either of these COAs while eligibility is being determined under Parent/Caretaker.

Medicaid eligibility for a child in foster care is determined first under the IV-E FC program. If ineligible under the IV-E FC program, Medicaid eligibility is determined under CWFC Medicaid.

Reference 2818 Chafee Independence Program Medicaid for eligibility criteria and procedures for Revenue Maximization, RSM Project and county offices.

A new application is not required at CMD when eligibility for a COA is terminated, and previously eligible AU members are subsequently approved for another COA.

A new application is not required if the previously eligible AU received a Q-track Medicaid COA based on an original application filed using Form DCH 700.

A new application is not required while completing a CMD for an AU member that is going to a higher or lower COA. For Family Medicaid, if the existing AU has trickled to a lower COA, a new application is required in order to process a CMD to a higher COA (such as from Children under 19 to Parent/Caretaker) if you are adding an existing BG member or new individual to the AU. If a CMD is processed to a higher COA, and all of the existing AU members are still covered (such as from TMA to Parent/Caretaker) a new application is not required. Refer to 2065 Family Medicaid Application Processing .

A new application is never required when approving Newborn Medicaid COA.

An interview is not required as part of the CMD process, including when adding an individual to an existing AU and when a new individual is included in the approval of a new COA as part of the CMD process. It may be necessary, however, to contact the AU by telephone, by mail or in person if the new COA requires information not included at the time of application for the terminated COA.

Follow the steps below to complete a CMD for an ABD or Family Medicaid denial or termination:

Step 1 Consider eligibility under all COAs (both ABD and Family Medicaid) prior to denial or termination of Medicaid. Step 2 Approve Medicaid under the COA that will provide the most medical coverage if the A/R meets all eligibility requirements for the COA. Step 3 Deny or terminate Medicaid if the A/R does not meet the requirements for any Medicaid COA. Step 4 Notify the A/R of his/her Medicaid eligibility as follows: Send adequate notice when completing the CMD on an application or changing COAs for a current Medicaid recipient Send timely notice if the CMD results in termination of Medicaid eligibility or the reduction of Medicaid benefits for a current recipient.

When completing CMD from Parent/Caretaker to TMA or 4MEX, timely notice is required.

Federal Law mandates that a CMD be completed on all SSI terminations before Medicaid can be terminated by DCH. As part of this CMD process, DCH will determine if continued eligibility:

should exist under SSA Section 1619(a) or (b) Work Incentives and, therefore, should be referred to SSA (See 2579 SSI 1619 Individuals ); OR

exists under another Medicaid coverage group and switch the individual to this new Medicaid coverage group.

As part of the automated Ex-Parte process, reports listing the names of individuals who have been converted to a new coverage group will be generated and received via Gateway. Refer to 2750 DCH Reports-Ex Parte Lists for specific instructions on how to complete the CMD process for an A/R terminated from SSI.

The Personal Responsibility and Work Opportunity Act of 1996, commonly referred to as the Welfare Reform Act, specifically prohibits individuals wanted in connection with a felony or in violation of the terms of their parole or probation or an outstanding warrant, from receiving SSI, Food Stamps, TANF benefits, and federal housing assistance. There is no prohibition written into federal law that prohibits these so called “fugitives” from receiving Medicaid. If someone is terminated from SSI due to their “fugitive” status Medicaid cannot be denied for the same reason. The fugitive could still be eligible for Medicaid provided he/she meets the requirements for some other group covered under the State’s Medicaid plan, such as the Adult Medically Needy program.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Retroactive Medicaid Effective Date: June 2021 Chapter: 2050 Policy Number: 2053 Previous MT Number(s): MT 57 Updated or Reviewed in MT: MT-64

Retroactive Medicaid provides Medicaid coverage for eligible individuals for the following time periods:

Three months prior to the month of application for ABD Medicaid, Family Medicaid and Supplemental Security Income (SSI).

SSI Intervening months - the month of application through the month of case disposition for SSI.

SSI Intervening Months are defined as follows:

the month of SSI application through the month of case disposition

Prior Months are defined as any of the following:

the three months prior to the month of a Medicaid application (ABD or Family Medicaid) filed with DFCS

the three months prior to the month of SSI application

DFCS determines eligibility for an SSI intervening Month only if SSI was denied for a financial reason or for a non-financial reason other than failure to meet disability.

Chafee Independence Program Medicaid was authorized as of July 1, 2008. No prior months are available under this COA prior to this date. Former Foster Care Medicaid was authorized as of January 1, 2014. No prior months are available under this COA prior to this date. Parent/Caretaker with Child(ren) Medicaid was authorized as of January 1, 2014. Prior months are available under Low Income Medicaid (LIM) regulations only. Children Under 19 Years of Age Medicaid was authorized as of January 1, 2014. Prior months are available under Right from the Start (RSM) Medicaid regulations only.

Eligibility may be determined for each retroactive/SSI intervening month under any ABD or Family Medicaid Class of Assistance (COA), regardless of the ongoing disposition of the application. See SSI prior month exceptions on page 3.

Potential eligibility for Medicaid for all retroactive/SSI intervening months is protected indefinitely for all Medicaid COAs including SSI. Medicaid can be approved at any time for any retroactive month if all eligibility criteria are met. (See “Prior Months for SSI Applicants” in this section for exceptions for use of SSI COA for SSI applicants).

DFCS does not make a determination on the same prior month(s) more than one time if the initial determination was a financial denial (over income, over resources, etc.) or a basic eligibility denial (citizenship/immigration status/identity, residency, disability, etc.).

For retroactive/SSI intervening months, the following criteria are not required:

enumeration

application for other benefits

cooperation with DCSS

Eligibility may be reconsidered for any month in which the denial was for a procedural reason (i.e. failure to provide verification, lack of information, etc.)

The A/R does not have to be re-interviewed or sign forms that were previously completed for the retroactive/SSI intervening month(s).

Medicaid eligibility is determined only for prior months in which the AU has incurred a Medicaid covered expense that remains unpaid. Verification of the expense is not required.

Services covered by Medicaid and NOT requiring Prior Authorization will be paid for approved retroactive months.

Do not make a DCSS referral if Medicaid is approved for retroactive Medicaid only.

Medicaid may be requested for the three prior months when adding an individual to a case. The day the request to add an individual is made determines the three prior months time period and is the application date for determining the three months prior.

Effective for all SSI applications filed on or after August 22, 1996, Social Security will not issue an SSI check for an eligible individual for the month of SSI application. The first month an SSI payment is made is the first month following the month of application, or the first month following the month that the individual becomes eligible for SSI with respect to that application, whichever is later.

The SSI status for the first month of payment is C01; the SSI status for the preceding month is E02. However, the E02 month is not an automatically Medicaid eligible month in DCH’s system unless it is followed by a month in pay status (C01). In those instances, treat the E02 month as a prior month.

The first month of SSI payment is not relevant to prior month(s) eligibility. The three months prior for an approved or denied SSI application are the three months prior to the month of SSI application.

Determine eligibility under any Medicaid COA for the first and/or second month(s) prior to the month of an approved SSI application.

Determine eligibility for the third month prior to the month of an approved SSI application under any Medicaid COA except SSI Medicaid.

EXAMPLE: If the SSI application month is January, the first prior month is December, the second prior month is November, and the third prior month is October.

Determine eligibility under any COA for the three months prior to an SSI denial.

Do not determine Medicaid eligibility for any month prior to a SSI application until SSA has completed its determination. Once SSA has made the determination, determine eligibility for the three months prior using the procedures outlined in this section. Abide by decisions made by SSA for intervening months except when Medicaid policy for a particular COA differs from SSI policy.

Determine retroactive ABD Medicaid eligibility through the month of death for the following individuals:

An individual who dies prior to applying for SSI

An individual who dies after applying for SSI

SSA will complete the SSI application process for a deceased individual only if s/he has a surviving spouse. If SSI is approved, SSI will be awarded for the month following the month of application through the month of the A/R’s death.

Follow the steps below to determine retroactive Medicaid Eligibility.

Step 1 For Family Medicaid, determine the AU and BG for each month requested. Refer to Chapter 2600, Assistance Units, for Family Medicaid. For ABD Medicaid, determine financial responsibility for each month. Refer to 2500 ABD Financial Responsibility and Budgeting Overview . An interview is not required. Additional required information may be obtained by telephone or by mail. Contact the A/R or personal representative (PR) acting on his/her behalf. A PR may provide information for a deceased A/R. This person should be knowledgeable about the A/R’s circumstances Step 2 Determine for which month(s) retroactive Medicaid is being requested and establish a class of assistance (COA) for each month. Refer to Chapter 2100, Medicaid Classes of Assistance. Step 3 Establish basic eligibility criteria for each month. Refer to Chapter 2200, Basic Eligibility Criteria. If the A/R applies for prior months as a disabled individual, disability must be verified for each prior month. Refer to 2205 Aged, Blind, Disabled Requirement for ABD Medicaid . Step 4 Determine financial eligibility for each month. Refer to Chapters 2500, ABD Financial Responsibility and Budgeting and 2650, Family Medicaid Budgeting. Use actual income and expenses for prior months. Use anticipated income and expenses for intervening months or actual income if available. For Family Medicaid COAs, if multiple, non-financial changes occurred in a retroactive month, use the circumstances on any day of the month that is most advantageous to the AU in determining eligibility. Step 5 Budget each prior month separately using the budgeting procedures for the COA chosen for that month. Step 6 Approve Medicaid under the appropriate COA if the A/R meets all eligibility criteria. Deny any ineligible months. If any AU members are ineligible, complete a CMD to consider Medicaid eligibility under all other COAs. Refer to 2052 Continuing Medicaid Determination . Step 7 Notify the AU. For MN cases, include the Begin Authorization Date (BAD) and spenddown information, if required. Step 8 Complete a Form 962 only if the retroactive month(s) cannot be transmitted electronically (i.e. more than 13 in the past and cannot be entered on GA Gateway). If Form 962 is necessary, annotate Form 962, “Please enter manually, cannot transmit via GA Gateway”. Forward Form 962 to the Gainwell Technologies Contact Center and upload a copy of the form with fax transmission report through Document Management in GA Gateway. Refer to Appendix C for the Member Contact Center mailing address.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Emergency Medical Assistance Effective Date: May 2026 Chapter: 2050 Policy Number: 2054 Previous MT Number(s): MT 71 Updated or Reviewed in MT: MT 79

Emergency Medical Assistance (EMA) provides medical coverage to individuals who meet all requirements for a Medicaid Class of Assistance (COA) except for citizenship/immigration status and enumeration requirements and have received an emergency medical service.

EMA does not provide coverage for Planning for Healthy Babies®, PeachCare for Kids®, Pathways, Nursing Home, or Waivered COAs. Other COAs such as AMN may provide potential coverage for those in LA-D.

A non-qualified immigrant applicant is potentially eligible for EMA under any Medicaid COA (except for P4HB, PCK, Pathways, NH, IH, EDWP, ICWP, NOW/COMP, Katie Beckett, or Hospice).

The applicant must meet all eligibility criteria for the COA with the following exceptions :

citizenship/immigration status

enumeration

Approval for EMA will be for a service that was provided prior to the date of application. Emergency Medical Assistance applications are not to be approved prior to an emergency, including labor and delivery. No future eligibility dates are to be used.

Chafee Independence Program Medicaid was authorized as of July 1, 2008. No EMA is available under this COA prior to this date.

Emergency Medical Assistance provides payment for the treatment of emergency services as defined in federal law in 1903 (v) of the Social Security Act and 42 CFR 440.255 when such care and services are necessary for the treatment of an emergency medical condition, provided such care and services are not related to either an organ transplant procedure or routine prenatal or postpartum care. An emergency is defined as acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

placing the patient’s health in serious jeopardy

serious impairment of bodily functions; or

serious dysfunction of any bodily organ or part

Services can include labor and delivery, from active labor until delivery is complete and mother and baby are stabilized.

A physician must determine the need for an emergency medical service and verify that the service has been rendered. The physician verifies emergency medical services by completing DMA Form 526, “Physician’s Statement for Emergency Medical Assistance”, or another written statement.

A written statement must include all information on the DMA Form 526, specifying the date(s) an emergency medical service has been rendered. No future eligibility dates are to be used. The form must contain an original signature.

The EW will accept DMA Form 526 and proceed with the eligibility determination, regardless of level or type of medical service rendered. DMA will determine if claims submitted by providers meet the definition of an emergency medical service. Only emergency medical services should be reimbursed.

Georgia residency is required and is established by the A/R’s verbal or written statement that s/he lives or has intent to live in the state and is physically present in Georgia.

An application for EMA is processed within 45/90 days. If an individual applies for an emergency medical service to be received at a future date, the application is denied, and the applicant may reapply after emergency services are provided.

A woman who is approved for Pregnant Women Medicaid EMA may also be eligible for EMA during the 12-month extended postpartum period if she receives emergency medical treatment during this period.

EMA is approved only for the date(s) specified on the DMA Form 526 or a physician’s written statement. In order for a Form 526 to be valid, it must have both a begin and an end date for services provided and the dates of service must be prior to the date the form is signed by the physician. No future eligibility dates should appear on the DMA Form 526.

A child born to a woman approved for EMA for the delivery is eligible for Newborn Medicaid. Refer to Section 2174 , Newborn Medicaid.

An EMA applicant/member has the right to request a Fair Hearing. Refer to Appendix B , Fair Hearings, for additional information.

A Continuing Medicaid Determination (CMD) is not required upon termination of EMA.

Other family members who meet citizenship/immigration status and enumeration requirements can request Medicaid coverage. Follow application procedures appropriate for any other COA for those family members.

Determine eligibility and provide notification of case disposition within the following Standards of Promptness (SOP):

within 45 days for pregnant women

within 45 days for Family Medicaid COAs and ABD COAs for aged, blind applicants

within 90 days for ABD COAs for disabled applicants

Follow the steps below to approve EMA:

Step 1 Obtain a signed application from the applicant and determine the appropriate COA under which EMA will be processed. Step 2 Review and obtain a signed Notification of Eligibility – Emergency Medical Assistance Program form from each individual making application for EMA. A copy of the signed notice should be placed in the case record. If the applicant is not present for a face-to-face interview, the EMA Notification form must be mailed to the applicant. It is preferable that the notice be signed and returned but it is not required. Step 3 Determine the AU and BG and complete the budgeting process for the appropriate COA. Step 4 Establish basic eligibility for the AU with the exception of citizenship/immigration status, and enumeration. Step 5 Obtain DMA Form 526 or a written, signed statement from the physician verifying the need for emergency medical services. The signature should be the original signature of the physician, or a medically trained employee of the physician designated to act on his/her behalf. Forms using the physician’s stamped signature are not acceptable. Faxes are acceptable if the form is faxed from the physician’s office and the signature on the faxed form was original. When questionable, contact the physician’s office to verify. The following providers are authorized to sign Form 526: Any qualified licensed professional (i.e., RN, MD, advanced practice RNs, midwife, PA, etc.) DMA Form 526 or physician’s statement should not indicate a period of emergency service exceeding 30 days from condition onset date. No future dates are to appear on DMA Form 526. In order for a Form 526 to be valid, it must have both a begin and an end date for services provided and the dates of service must be prior to the date the form is signed by the physician or qualified licensed professional. Step 6 Approve the case using the appropriate COA if the applicant meets all eligibility criteria. Notify the AU of the eligibility determination. The notice should include the following: approval/disposition date Gateway Client ID number date(s) of eligibility Step 7 A CMD is not required. Applicants will need to complete a new application for subsequent emergency services received.

Refer to Appendix B , Hearings.

Providers should submit claims for services rendered to EMA applicants, on the web portal at mmis.georgia.gov/portal with supporting documentation. Supporting clinical documentation should include form 520 (Provider Inquiry Form), history and physical, any emergency room records, physician’s progress notes, physician order sheets, discharge summary, consultation record, nurse’s notes, and death summary if applicable. Claims without supporting documentation will be denied as incomplete. Providers can follow the procedures for prior approval for clearance as to whether a medical charge or prescription will be covered. However, prior approval does not guarantee payment. Providers who do not routinely submit EMA claims for review and possible payment by Department of Community Health (DCH) should attempt to provide some notice of such policy to the potential EMA member. DCH strongly encourages providers to negotiate payment plans that assist these members with payment of these services. If DCH determines that the EMA claim contains both emergent and non-emergent services, payment will only be rendered for emergency services. Providers will be informed by Gainwell of the need to submit additional documentation to facilitate the rendering of such payment.

Failure to submit the required documentation within 30 days of the date of the split decision notice will result in the denial of the entire claim. If DCH determines that services rendered were non-emergent, providers may bill EMA members for those services. DCH strongly encourages providers to negotiate payment plans that assist these members with payment of these services. Denial of EMA claims are subject to the administrative appeal process as outlined in Part I, Chapter 500. EMA claim denials that result from a provider’s failure to submit these claims according to this subsection are subject to the provisions of Part I, § 106(Q).

For instructions on prior approval providers can refer to Part I Policy and Procedure in the Gainwell Technologies Billing Manual.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Sponsored Aliens Effective Date: December 2019 Chapter: 2050 Policy Number: 2055 Previous MT Number(s): MT 1 Updated or Reviewed in MT: MT-57

Aliens who are ineligible for SSI because of income or resources deemed from a sponsor may be determined eligible for Medicaid without considering the income or resources of the sponsor.

Aliens who are admitted to the United States as permanent residents often have a sponsor. The income and resources of a sponsor and his/her spouse are used by SSI in determining the financial eligibility of an alien.

The Social Security Administration (SSA) deems the sponsor’s income and resources in the SSI eligibility determination for up to five years. The five-year period begins with the month the alien is admitted to the U.S. for permanent residence or is granted permanent resident status.

SSA may waive deeming from the sponsor when the alien’s disability or blindness begins at either of the following points:

After entry into the U.S. for permanent residence

After becoming a permanent resident The income and resources of a sponsor are not considered in Family Medicaid budgeting.

Follow the steps below to process the Medicaid application of a sponsored alien.

Step 1 Verify the alien’s SSI application was denied based on the sponsor’s income or resources. If the A/R is denied SSI solely due to the sponsor’s deemed income or resources, consider eligibility for Medicaid under any class of assistance, including SSI Medicaid. Step 2 Determine eligibility for Medicaid without considering the income and resources of the sponsor. Consider retroactive and ongoing eligibility. A reduction in the income and resources of the sponsor, the sponsor’s spouse or the A/R may make the A/R eligible for SSI. Remind the A/R and sponsor to report changes in financial circumstances. Step 3 Verify the month SSI will stop counting the income and resources of the sponsor. Step 4 Complete the CMD at least one month before the month SSI will stop counting the income and resources of the sponsor to determine if the alien is SSI eligible or eligible under a COA other than SSI Medicaid. Refer to 2052 Continuing Medicaid Determination . Step 5 Obtain DMA Form 526 or a written, signed statement from the physician verifying the need for emergency medical services. The signature should be the original signature of the physician or a medically trained employee of the physician designated to act on his/her behalf. Forms using the physician’s stamped signature are not acceptable. Faxes are acceptable if the form is faxed from the physician’s office and the signature on the faxed form was original. When questionable, contact the physician’s office to verify.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: ABD Medicaid Application Processing Effective Date: December 2025 Chapter: 2050 Policy Number: 2060 Previous MT Number(s): MT 73 Updated or Reviewed in MT: MT-78

The ABD Medicaid application process begins with the request for health coverage and ends with notification to the Assistance Unit (AU) of the eligibility status.

Eligibility for ABD Medicaid Classes of Assistance (COA) is determined in the following order:

FBR COAs

LA-D/ Medicaid Cap COAs

Q-Track

ABD Medically Needy

QMB and SLMB may be approved while an eligibility determination for Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance to Needy Families (TANF) or another Medical Assistance COA is pending. A member cannot be dually eligible for QI-1 and another COA with the exception of AMN Spenddown.

An application for any ABD Medicaid COA may be processed from any of the following application documents:

Form 297 Application for TANF, SNAP, or Medical Assistance

Form 508 SNAP, TANF, Medical Assistance Renewal Form

Form 632 Presumptive Eligibility (PE) for Pregnancy

Form 632H Qualified Hospital Presumptive Eligibility Application

Form 632W Presumptive Eligibility (PE) Women’s Health Medicaid Application

Form 700 Application for Medicaid & Medicare Savings for Qualified Beneficiaries

Form 94 Medicaid Application

Form 94A Medicaid Streamlined Application

Federally Facilitated Marketplace (FFM) application (Obsolete as of 12/2024)

GA Access Application

Gateway Medical Assistance Online Application

Gateway Medical Assistance Renewal

Low Income Subsidy Application – SSA 1020B (LISA- application for Medicare Part D)

PeachCare for Kids® Application (Obsolete as of 09/2017)

Provider Portal Online Application

SSA Model Medicare Savings Plan (MSP) application

SUCCESS Application for Assistance (AFA) (Obsolete as of 09/2017)

Women’s Health Medicaid Review Form (Obsolete as of 12/2022)

A completed application consists of a signed (either written, not typed, or electronic such as via Gateway) application with information sufficient to contact the A/R or authorized representative (AREP). Refer to 2050-Application Processing Overview . The signature does not necessarily have to be that of the A/R. Any information that is missing, incomplete or otherwise unclear may be obtained from the A/R or AREP after the signed application is received and registered in the system by the agency.

A new signed application is required in the following situations:

When adding a program for an A/R who has been an ineligible spouse in an active AU and who is now requesting Medical Assistance for him or herself under a different COA from a recipient spouse.

An application was previously correctly denied due to failure to provide required verification. A/R wants to reapply in a subsequent month for ongoing benefits. Although the application date is protected, the A/R should sign another application unless there is good cause for not initially providing the verification.

An application was previously correctly denied due to not meeting a basic or financial eligibility criteria. A/R now meets these criteria and wants to reapply for ongoing benefits. Have the A/R complete and sign another application.

A new application is NOT required in the following situations:

If the system denies the application because the worker has not acted timely on the case

If the A/R is already a Medical Assistance recipient and is changing to another COA, a Continuing Medicaid Determination (CMD) is being completed or if an SSI recipient is entering a NH

If a current recipient is being added as a recipient to an existing AU, such as SSI added to Q-Track or Q-Track added to AMN

A non-applicant is added to an existing AU, even if the AU cascades to a lower COA or the spenddown amount is increased.

Homeless AUs are NOT required to provide a physical address but must provide sufficient information to establish Georgia residency. The applicant’s statement is acceptable unless conflicting information is known to the agency.

Screen the application to determine the following:

current receipt of the benefits for which the A/R is applying

current receipt of other benefits available.

A face-to-face (FTF) interview is not a requirement for any Medicaid COA. At the caseworker’s discretion or the request of the A/R or AREP, a FTF interview may be scheduled; however, an application may not be denied for failure to appear for an interview.

A telephone interview is required for ABD LA-D COAs and Adult Medically Needy (AMN) COAs.

Caseworker will attempt to reach the A/R or AREP by conducting two unscheduled telephone attempts prior to scheduling an interview.

The A/R considered to be is the primary source of information for him or herself. The A/R may authorize an Authorized Representative (AREP) to apply, interview, and provide information on his or her behalf. An elected AREP may have verbal or written designation. If the designation is written, the applicant’s signature is required. If the designation is verbal, it must be documented. If the information is provided by an AREP is questionable or unclear, attempt to contact the A/R for clarification. This may be accomplished by telephone, mail, fax or in-person,

The A/R may withdraw, at any time, authorization of an AREP to act on his or her behalf. This request can be given verbally or in writing. If the request is given verbally, it must be documented. If the request is written, the applicant’s signature is required.

Information necessary to complete an eligibility determination may be obtained by any of the following methods:

FTF interview

A FTF interview may not be required of the applicant or AREP and an application may not be denied solely for failure to complete a FTF interview.

telephone call

mail

home visit

secure e-mail

Fax

Gateway

Orally or in writing, inform the A/R about the Medicaid program(s) for which he or she may be entitled. Provide relevant information pamphlets or other printed material.

Explain the following information to the A/R and/or AREP:

services provided by DFCS and how to obtain those services

requirements of eligibility and the A/R’s responsibility to provide correct information to establish eligibility and benefit level.

HIPAA and confidentiality

basic and financial eligibility requirements

Clearinghouse requirements for any AU/BG member

potential Medical Assistance COAs

potential coverage for three months prior to the month of application

periodic renewals

timely reporting of changes and how and where changes are to be reported

assignment of Third Party Liability (TPL)

Medically Needy requirements, if applicable

patient liability or cost share, if applicable

The applicant’s right to the following: a fair hearing. Refer to Appendix B - TOC for details a decision within the standard of promptness (SOP) confidentiality non-discrimination in the processing of the application their rights and responsibilities in the Medical Assistance program, included in the single streamlined application or Form 297A - Rights and Responsibilities.

Complete the mandatory forms below when processing an ABD Medicaid application.

Application for Assistance (AFA) (Obsolete as of 09/2017)

Form 297A, Rights and Responsibilities ( only if Form 297 is used to apply)

Form 5460 - Notice of Privacy Practices (HIPAA) Form 5460 - Notice of Privacy Practices and Form 297A - Rights and Responsibilities may be mailed to the applicant. The applicant is NOT required to sign and return either form, provided the case record is documented that these forms were sent.

Form 216 - Declaration of Citizenship (conditionally mandatory, see Note below) This form is not required if 94 (rev. 5/10 or later), Form 94A, 297, 508 (Rev. 5/12 or later), 700 (Rev.11/09 or later), Gateway Medical Assistance application, or FFM application are used as they contain the required language to meet the needs of the declaration.

Form DMA 285 - Third Party Liability Health Insurance Questionnaire, when the person has other health insurance coverage. See Section 2230 - Third Party Liability for requirements. A Form DMA 285 - Third Party Liability Questionnaire is not required when application is made for QMB, SLMB, or QI-1 via Form 700. Send a copy of Form 700 to DCH/TPL in lieu of Form DMA 285 if the client has medical insurance. Attach a copy of the insurance card, front and back, if available.

Complete any other forms as necessary depending on the COA and the A/R’s circumstances.

Determine if the A/R meets all points of eligibility.

Complete mandatory clearinghouse requirements.

Follow appropriate documentation standards for ABD Medicaid.

Explore Medicaid eligibility for the three prior months.

Obtain required verification.

For LA-D A/Rs whose income exceeds the Medicaid Cap, provide the following as a handout to the A/R or AREP:

Form 936 - Certification of DCH Approved Qualified Income Trust

Form 945 - Qualified Income Trust (QIT) – A Guide for Trustees

Form 946 - Qualified Income Trust (QIT) Worksheet

Form 948 - QIT Approved Template 1

Eligibility should be processed as soon as all verification is received, this should take no longer than the following time frames:

45 calendar days beginning with the application date for aged or blind applicants.

90 calendar days beginning with the application date for disabled applicants whose disability that has not already been established by Disability Adjudication Section (DAS) for the Social Security Administration (SSA) or the State Medical Eligibility Unit (SMEU)

10 working days beginning with the application date for all Q-Track applicants.

The standard of promptness is 90 calendar days when a disability decision is required before the eligibility determination can be completed. However, if a separate disability decision is not required, the 45-calendar day standard of promptness applies.

If the 45 or 90-day SOP date falls on a weekend or holiday, complete the application by the last workday prior to the weekend or holiday.

Observe the following standards in processing ABD applications:

Register the application within 24 hours of the agency’s receipt of the application.

If the A/R or AREP is not interviewed on the same day an institutional COA application is filed, contact the A/R or AREP within a reasonable timeframe to conduct the required telephone interview.

If the A/R or AREP is not interviewed on the same day a non-institutional COA application is filed, and additional information is required, contact the A/R or AREP within a reasonable timeframe.

If verification or additional information is required, complete a verification checklist and mail or provide to the A/R or AREP. Establish a reasonable deadline for returning the requested verification.

If the A/R or AREP fails to meet the deadline for providing additional information, attempt to contact the A/R or AREP to assess the need for an extension of the deadline or the possibility of assisting in obtaining required verification. Do not deny an application for failure to provide verification if the verification can be obtained by the caseworker.

Contact the nursing home or appropriate case manager by the 30 th calendar day from the application date if the LOC instrument has not been received. Document and follow-up as necessary.

Deny an application at the first point ineligibility is established. Do not leave a case pending in anticipation of the A/R becoming eligible at a date beyond the ongoing benefit month.

Deny the application within two days of SOP if the nursing home or case manager has failed to submit the LOC instrument to the authorized approval source. If the LOC approval source has received the LOC instrument but has not yet completed it, do not deny the application.

Do not deny an application solely because the 10 th , 45 th , or 90 th day has been reached, and eligibility cannot yet be determined.

Deny an application before the SOP if the A/R or AREP fails to cooperate in the application process or fails to supply necessary information that he or she is capable of obtaining and DFCS has no direct means of obtaining.

Determine if the A/R meets all points of eligibility.

Process applications in chronological order, when possible, with the exception of Q-Track applications, based on the following:

date of application

whether all information is available to determine eligibility. See Standard of Promptness (SOP) for SOP guidelines.

If eligible, approve the application ongoing and for any retroactive months, if appropriate.

Provide adequate notification to the A/R of the eligibility determination. A copy may also be sent to a AREP at the request of the A/R. Adequate notification includes the reason(s) for any action taken.

The notice must include the following:

the basis for the approval, denial, or termination

the period of eligibility

the reason for the action

the A/R’s right to request a fair hearing (Refer to Appendix B - Hearings TOC )

the telephone number of the DFCS Call Center

the telephone number of legal services

the amount of medical expenses required to meet the ABD Medically Needy spenddown, if the A/R meets all eligibility requirements other than income.

For LA-D cases in which a penalty is imposed: the duration of the penalty, the Form 411 - Undue Hardship Waiver Form Application and information that the A/R has 14 days in which to submit the form with supporting information to the caseworker.

See Section 2342 - Transfer of Assets and Appendix F:Forms - TOC for the form.

Approve Medicaid and continue eligibility as long as the A/R continues to meet the requirements of the COA under which they are approved. A CMD must be completed prior to denial or termination of any Medicaid COA. Refer to Section 2052 - Continuing Medicaid Determination.

A COA that has been approved using EMA criteria does not require a CMD when terminated.

Conduct a property search on required ABD Medicaid applicants for the following reasons:

to verify the value and status of all real property in which the A/R or deemor declare ownership interest.

to detect any undisclosed property in which the A/R or deemor may have ownership interest.

to detect and verify any transfer of real property affected by the A/R.

A property search must be completed if a questionable situation regarding ownership of property is discovered during the eligibility determination process.

If necessary, conduct a property search by checking the current tax digest and transfers for the past 60 months in the grantee/grantor book for the county in which the A/R resides or did reside prior to entering LA-D.

Chart 2060.1 – ABD Medicaid Property Search Requirements

If: then a search of the TAX DIGEST is: and a search of the GRANTEE/GRANTOR record is: the COA is AMN Not required, unless questionable Not required, unless questionable the COA is LA-D Required Required the COA is a Public Law or SSI Required Not required, unless questionable the COA is Q-Track only Not required, unless questionable Not required, unless questionable the A/R has not lived in Georgia during the 24 months prior to the month of application Not required Not required, unless questionable

Request assistance in completing a property search from the DFCS office in another county where the client may have resided for a substantial period of time before moving to the current county of residence using Form 991 - MAO Property Search Record . Review the exceptions to property search requirements to determine the necessity for a property search.

The Social Security Administration (SSA) accepts and processes applications for Supplemental Security Income (SSI) at local SSA offices. Any individual applying for ABD Medicaid at DFCS who appears to be financially eligible for SSI should be referred to the local SSA office to file an application. DFCS will also accept the ABD application for a Medicaid determination and begin the SMEU process. An exception to this may be QMB in some situations.

SSI applicants have the right to have any month for which they have been determined ineligible for an SSI payment for a reason other than failure to meet the disability criteria examined for eligibility under ABD Medicaid. Refer to Section 2053 - Retroactive Medicaid .

DFCS is responsible for determining Medicaid eligibility on SSI applicants in the following circumstances:

the three months prior to the month of SSI application for SSI approvals and denials

months associated with an SSI application for which the applicant is ineligible for an SSI payment for a reason other than failure to meet disability

if an individual is alleging a disability regardless of SSI application status.

An SSI applicant who wants a determination of ABD Medicaid eligibility for months associated with a denied SSI application for reasons other than disability or prior months should contact DFCS to apply for that period of time. The prior months are protected indefinitely until such time as an eligibility determination has been made.

Refer to Section 2053 - Retroactive Medicaid , for processing procedures for retroactive months associated with an SSI application.

Chart 2060.2 - ABD MEDICAL ASSISTANCE FORM REQUIREMENTS

Form 216 - Declaration of Citizenship/Immigration status is not required if the A/R has declared their citizenship or immigration status on the eligibility application (94, 94A, 297, 508, 700 or via Gateway Customer Portal application) and signed application under penalty of perjury. Also, declaration of citizenship/immigration status/identity is not required if the A/R is determined under EMA procedures. Refer to Section 2215 - Citizenship/Immigration/Identity .

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Family Medicaid Application Processing Effective Date: December 2025 Chapter: 2050 Policy Number: 2065 Previous MT Number(s): MT 74 Updated or Reviewed in MT: MT 78

The Family Medical Assistance application process begins with the request for health coverage and ends with notification to the Assistance Unit (AU) of the eligibility status.

Family Medical Assistance eligibility is determined in the following order:

Newborn

Pregnant Women Medicaid

Parent/Caretaker with Child(ren) Medicaid

other Family Medicaid Classes Of Assistance (COA) based on Parent/Caretaker with Child(ren) eligibility criteria, i.e., TMA, 4MEx

Children Under 19 Years of Age Medicaid

PeachCare for Kids®

Family Medicaid Medically Needy

Women’s Health Medicaid (WHM)

Pathways

Planning for Healthy Babies® (P4HB)

GA Access

Medicaid eligibility for a child in foster care is determined first under the IV-E FC program. If ineligible under IV-E FC, Medicaid eligibility is determined under CWFC Medicaid. Refer to Chapter 2800 - Assistance to Children in Placement .

An application for any Family Medical Assistance COA may be made with any of the following forms:

Form 297 - Application for TANF, SNAP, or Medical Assistance

Form 508 - SNAP, TANF, Medical Assistance Renewal Form

Form 632 - Presumptive Eligibility (PE) for Pregnancy

Form 632H - Qualified Hospital Presumptive Eligibility Application

Form 632W - Presumptive Eligibility (PE) Women’s Health Medicaid Application

Form 700 - Application for Medicaid & Medicare Savings for Qualified Beneficiaries

Form 94 - Medicaid Application

Form 94A - Medicaid Streamlined Application

Federally Facilitated Marketplace (FFM) application (Obsolete as of 12/2024)

GA Access application

Gateway Medical Assistance Online Application

Gateway Medical Assistance Renewal

Low Income Subsidy Application – SSA 1020B (LISA- application for Medicare Part D)

PeachCare for Kids® Application (Obsolete as of 09/2017)

Provider Portal Online Application

SSA Model Medicare Savings Plan (MSP) application

SUCCESS Application for Assistance (AFA) (Obsolete as of 09/2017)

Women’s Health Medicaid Review Form (Obsolete as of 12/2022)

A completed application consists of a signed (either written, not typed, or electronic such as via Gateway) application with information sufficient to contact the A/R or authorized representative (AREP). The signature does not necessarily have to be that of the A/R. Any information that is missing, incomplete or otherwise unclear may be obtained from the A/R or AREP after the signed application is received and registered in the system by the agency.

A new signed application is required in the following situations:

An application requesting coverage for Medical Assistance for a BG member who had not requested coverage for him or herself on the last application filed.

An application was previously correctly denied due to failure to provide required verification. Applicant wants to reapply in a subsequent month for ongoing benefits. Although the application date of the first application is protected, the applicant should sign another application unless there is good cause for not initially providing the verification.

An application was previously correctly denied for not meeting a basic or financial eligibility criteria. A/R now meets the criteria and wants to reapply for ongoing benefits. Have the applicant complete and sign another application.

An applicant applied for him or herself and children, but the case trickled to a lower COA. A change then occurs that would make him or her eligible.

An application was previously correctly denied for failure to submit PeachCare for Kids ® initial premium payment by the required due date.

A new application is NOT required in the following situations:

If the system denies the application because the worker has not acted timely on the case.

If the applicant is already a Medical Assistance recipient and is changing to another COA, or a Continuing Medicaid Determination (CMD) is being completed.

Adding a Newborn Medicaid case

If a BG member is being added.

When removing the Reasonable Opportunity Period (ROP) penalty, or adding a child back, to the active AU effective the first day of the month that citizenship/immigration/identity verification was provided.

MAGI COA cases (except for P4HB) that close for failing to return verification will be reinstated if all the verification is returned within 90 days of closure; an application will not be required. Refer to Section 2706 - Medicaid Renewals .

Homeless AUs are NOT required to provide a physical address but must provide sufficient information to establish Georgia residency. The applicant’s statement is acceptable unless conflicting information is known to the agency.

Screen the application to determine the following:

current receipt of the benefits for which the AU is applying

current receipt of other benefits.

A face-to-face (FTF) interview is not required for any Family Medical Assistance COA. At the caseworker’s discretion or the request of the applicant or AREP, a FTF interview may be scheduled, however an application may not be denied for failure to appear for an interview.

The A/R is considered to be the primary source of information for him or herself. The A/R may authorize an Authorized Representative (AREP) to apply and provide information on his or her behalf. An elected AREP may have verbal or written designation. If the designation is written, the applicant’s signature is required. If the designation is verbal, it must be documented. If information provided by an AREP is questionable or unclear, attempt to contact the A/R for clarification. This can be accomplished by telephone, mail, fax or in-person.

The A/R may withdraw, at any time, authorization of an AREP to act on his or her behalf. This request can be given verbally or in writing. If the request is given verbally, it must be documented. If the request is written, the applicant’s signature is required.

Information necessary to complete an eligibility determination may be obtained by any of the following methods:

FTF interview A FTF interview may not be required of the applicant or AREP and an application may not be denied solely for failure to complete a FTF interview.

telephone call

mail

home visit

fax

secure email

Gateway

Orally or in writing, inform the A/R about the Medical Assistance program(s) for which she or he may be entitled. Provide relevant information pamphlets or other printed material. Explain the following information to the A/R or AREP:

services provided by DFCS and how to obtain those services

refer the A/R to other appropriate services such as family planning

requirements of eligibility and the A/R’s responsibility to provide correct information to establish eligibility and benefit level

HIPAA and confidentiality

basic and financial eligibility requirements

Clearinghouse requirements for any AU/BG member

potential Medical Assistance COAs

potential coverage for three months prior to the month of application

periodic renewals

timely reporting of changes and how and where changes are to be reported

assignment of Third-Party Liability (TPL)

Medically Needy requirements, if applicable

the role of the Division of Child Support Services (DCSS), assignment of medical support rights to the State, and Good Cause for non-compliance

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Referrals to anyone in the AU under the age of 21. Information regarding EPSDT and contact information is included on the GA Gateway approval notice. Refer to Section 2930 - Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) .

Woman Infant and Children (WIC) Referrals to anyone in the AU that is pregnant; breastfeeding; postpartum women; or has a child under the age of 5 years, Section 2985 - Women, Infant and Children (WIC) Services .

the applicant’s right to the following: a fair hearing (Refer to Appendix B - TOC for details), a decision within standard of promptness (SOP), confidentiality, non-discrimination in the processing of the application, their rights and responsibilities in the Medical Assistance program, included in the single streamlined application or Form 297A - Rights and Responsibilities .

In addition, explain the following to an AU that includes a pregnant woman:

the right to apply and how to apply for TANF 45 days prior to the expected date of delivery

continuous financial eligibility for the pregnant woman

presumptive eligibility (PE) Medicaid process and how to apply at a public health facility or other qualified provider if the Medicaid eligibility determination for the pregnant woman cannot be made the same day that the application is filed. Accept the Medicaid application even if the applicant applies for PE Medicaid.

Complete the mandatory forms below when processing a Family Medical Assistance application:

Application for Assistance (Obsolete as of 09/2017)

Form 297A - Rights & Responsibilities ( only if Form 297 is used to apply).

Form 216 - Declaration of Citizenship/Immigration Status (conditionally mandatory, please see Note below) This form is not required if Form 94 (Rev. 5/10 or later), Form 94A - Medicaid Streamlined Application , 297 - Application for TANF, Food Stamps, or Medical Assistance , 508 - Food Stamp TANF Medicaid Renewal Form (Rev. 5/12 or later), 700 - Application for Medicaid & Medicare Savings for Qualified Beneficiaries (Rev. 11/09 or later), Gateway Medical Assistance Online application, or GA Access application are used as they contain the required language to meet the needs of the declaration.

Form 5460 - Notice of Privacy Practices (HIPAA) Form 5460 - Notice of Privacy Practices (HIPAA) and Form 297A - Rights and Responsibilities may be mailed to the applicant. The applicant is NOT required to sign and return either form, provided the case record is documented that the forms were sent.

Form DMA 285 - Third Party Liability Questionnaire, when the person has other health insurance coverage. See Section 2230 - Third Party Liability for when a Form DMA 285 - Third Party Liability Questionnaire can be waived, and for other TPL requirements. A Form DMA 285 - Third Party Liability Questionnaire is not required for children in placement. For MAGI COAs a separate Form DMA 285 - Third Party Liability Questionnaire is not required if the Form 94A - Medicaid Streamlined Application or pre-populated renewal form 508M has the TPL information included, and the form is signed.

Form 138 - Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate in Child Support Services (if a DCSS referral is required) Form 138 - Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate in Child Support Service may be mailed to the applicant. The applicant is NOT required to sign and return the form provided the case record is documented that the form was sent. If the application or renewal is completed using Gateway Medical Assistance Application, Gateway Medical Assistance Renewal, or Form 94A - Medical Assistance Streamlined Application , then Form 138 – Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate in Child Support Services is not required as the 138’s language is included.

When the Form 94A - Medicaid Streamlined Application is used it also incorporates the Declaration of Citizenship/Immigration status and TPL; separate forms are not required.

Complete any other forms as necessary depending on the COA and the A/R’s circumstances.

Determine if the A/R meets all points of eligibility.

Complete mandatory clearinghouse requirements.

Follow appropriate documentation standards for Family Medical Assistance.

Explore Medical Assistance eligibility for the three prior months.

Obtain required verification.

Refer to Chart 2065.1 - Family Medical Assistance Form Requirements in this section.

The eligibility determination for Family Medical Assistance COAs should be completed with real time determinations or as soon as all verification is received. This should take no longer than the following time frames:

10 days from the date of application for pregnant women, regardless of COA

45 days for EMA-PGW

10 days from the date of report for newborns, regardless of COA

This pertains to a child born to a woman who was eligible for and receiving Medical Assistance on the day the child was born who most commonly is approved for Newborn COA but could be approved/dual eligible for another COA, such as Parent/Caretaker.

45 days from the date of application for all other Family Medical Assistance COAs

Calculate the SOP beginning with the date of application. Document the reason for any delays in the case record.

If the SOP date falls on a weekend or holiday, complete the application by the last workday prior to the weekend or holiday.

Observe the following standards in processing Family Medical Assistance applications.

Accept the signed application on the day the application is received by the agency.

Register the application using the date the application was received by the agency or qualified provider. See Application Date for details. The application must be registered within 24 hours of receipt by the agency.

If the applicant or AREP is not contacted on the same day an application is filed and additional information is required, contact the applicant or AREP within a reasonable timeframe to obtain the information necessary to complete the application.

If verification or additional information is required, complete a verification checklist and mail or provide to the A/R or AREP. Establish a reasonable deadline for returning requested verification. Refer to Section 2051 - Verification .

If incomplete verification is returned, send another checklist specifying what is required; establish a new reasonable deadline for returning requested verification.

If the applicant or AREP fails to meet the deadline for providing additional information, attempt to contact the applicant or AREP to assess the need for an extension of the deadline or the possibility of assisting in obtaining required verification. Do not deny an application for failure to provide verification if the verification can be obtained by the caseworker.

Deny an application at the first point ineligibility is established. Do not leave a case pending in anticipation of the applicant becoming eligible at a future date beyond the ongoing benefit month.

Do not deny an application solely because the SOP has been reached and eligibility cannot yet be determined.

Deny an application before the SOP if the applicant or AREP fails to cooperate in the application process or fails to supply necessary information that she or he is capable of obtaining and DFCS has no direct means of obtaining.

Determine if the AU meets all points of eligibility.

Process applications in chronological order, with the exception of Medicaid coverage for pregnant women, based on the following:

date of application

whether all information is available to determine eligibility

If eligible, approve the application, within 45 days, for all eligible months including retroactive and ongoing months. Process applications for pregnant women within 10 days to ensure early prenatal care.

Provide the applicant adequate written notification of the eligibility determination. Adequate notification includes the reason(s) for any action taken.

A duplicate notice may be provided to the AREP upon request by the applicant. The applicant, however, must receive all notices regarding his or her case(s).

Notification must explain the following:

the basis for the approval/denial/termination

the period of eligibility

the reason for the action

the AU’s right to request a fair hearing (Refer to Appendix B - Hearings for details)

the telephone number of the DFCS Call Center

the telephone number of legal services.

Generic denial reasons may be used as a secondary or tertiary denial/termination reason, but never as the sole reason for denial/termination.

Approve Medical Assistance and continue eligibility as long as the AU continues to meet the requirements of the COA under which eligibility was approved. A Continuing Medicaid Determination (CMD) must be completed prior to denial or termination of any Medical Assistance COA. Refer to Section 2052 - Continuing Medicaid Determination .

Certain COAs are time-limited. Refer to Chapter 2100 - Classes of Assistance .

Chart 2065.1 - Family Medical Assistance Form Requirements

* Form 216 - Declaration of Citizenship/Immigration status is not required if the A/R has declared their citizenship or immigrations status on the eligibility application (94, 94A , 297 , 508 , 700 , Gateway Medical Assistance Online application, or GA Access application) and signed application under penalty of perjury. Also, declaration of citizenship/immigration/identity is not required if the A/R is determined under EMA procedures. Refer to Section 2215 - Citizenship/Immigration/Identity . * * Form 138, Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate in Child Support Services is not required if the application or renewal is via Gateway or 94A as the 138’s language is included in both. Refer to Section 2250 - Cooperation with Division of Child Support Services .

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Placement Outside The Home Effective Date: December 2019 Chapter: 2050 Policy Number: 2066 Previous MT Number(s): MT 51 Updated or Reviewed in MT: MT-57

An individual living in a placement outside the home may, under certain circumstances, be eligible for Family or ABD Medicaid.

An individual is potentially eligible for Medicaid if any one of the following situations exist:

an individual admitted to a medical institution to receive medical care An individual incarcerated or placed in a detention facility who is admitted to a medical treatment facility is considered a resident of the detention facility and is therefore ineligible for Medicaid.

an individual in a private community facility such as a homeless shelter or a shelter for victims of domestic violence

a child in a private child care institution that provides 24-hour non-secure custodial care, such as a children’s home

a child in a family licensed home supervised by the Department of Juvenile Justice (DJJ)

an child in a private licensed group home

a child in a family foster home approved by one of the following agencies: DFCS Child Services and Family Counseling The United Methodist Children’s Home The Georgia Baptist Children’s Home (Palmetto Campus) DJJ (as contract home or attention home) Social Services verifies that a placement has been made in an approved facility.

an individual in a licensed emergency shelter

a child placed in any other public or private agency, which DFCS approves for placement.

For Medicaid eligibility purposes, the following placement facilities are not considered public institutions:

public educational or vocational training institution

publicly operated general hospital

publicly operated nursing home

publicly operated community residence or group home that serves no more than 16 individuals

public child care institution that accommodates no more than 25 children and the child is approved to receive Title IV-E foster care payments

an intermediate care facility for the mentally disabled (nursing home unit), even if located on the premises of a public institution

Normally Medicaid is not approved for individuals residing in public institutions, such as Georgia Regional Hospital. However, some of these institutions have Medicaid participating nursing homes associated with them. If a level of care instrument is received from one of these facilities, proceed with the Medicaid eligibility determination.

An individual is ineligible for Medicaid if any of the following situations exist:

the individual is incarcerated in a jail, prison or other facility operated primarily for detention

a child is placed in a detention facility, such as a Youth Development Campus (YDC) A child placed temporarily in a Regional Youth Detention Center (RYDC) or YDC while awaiting transfer to a private facility may be eligible for Medicaid.

the individual is placed in a public institution If the placement in the public institution is temporary while awaiting a private placement more appropriate to the needs of the individual, the individual is potentially eligible for Medicaid. (See NOTE above.)

the individual is legally committed to an institution, whether public or private

the individual is placed in an institution operated for the treatment of tuberculosis

An individual placed by a state agency in an out-of-state institution or licensed foster care facility is considered a legal resident of the state making the placement.

The state of origin is responsible for the medical expenses of the child.

If the individual is a IV-E eligible child and IV-E payments are made, the child can be approved for Medicaid in the state where the child is placed. Refer to Chapter 2800 for IV-E Foster Care/Adoption Assistance policy.

The placement facility may locate a local doctor, dentist or other medical provider who will enroll as a Medicaid provider in the state of origin.

If no providers are willing to enroll for the other state’s Medicaid, notify the state office Medicaid Policy Unit.

A child placed by a parent or other responsible adult in a private placement facility or LA-D may be eligible for Family or ABD Medicaid.

For Family Medicaid, the child placed in a private childcare (residential) institution is considered as an AU of one (1) and no longer in the home of the family. A child placed in a psychiatric hospital by a parent or other caretaker relative would be considered absent from the home for treatment or training and would not be considered as an AU of one (1).

Refer to Chapter 2600, Family Medicaid AUs and BGs.

For FM, budget any money received by the facility for the child. If the parents provide money, it is considered child support and the $50 child support deduction is allowed. If another responsible adult provides money, it is considered a contribution.

For ABD Medicaid, see Section 2225 , Residency for determining state of residence.

Use the following chart of situations to determine if an individual is potentially eligible for Medicaid based on current living arrangement outside the home:

CHART 2066.1 INDIVIDUALS IN PLACEMENT OUTSIDE THE HOME Situation Medicaid Eligibility If the individual is placed in: Then s/he is Medicaid a public institution Temporary arrangement awaiting a more appropriate placement for his/her needs in a private facility ineligible eligible a public childcare institution that accommodates no more than 25 children and the child is receiving Title IV-E foster care payments eligible a publicly operated community residence or group living home that serves no more than 16 individuals (example: residential drug treatment center operated by the Mental Health Division of DHS) eligible a public educational or vocational training institution eligible a publicly operated general hospital eligible a publicly operated nursing home or hospice provider eligible a Regional Youth Detention Center operated by DJJ eligible a prison, jail or other incarceration facility operated primarily for detention ineligible a Youth Development Campus Temporary arrangement awaiting a more appropriate placement for his/her needs in a private facility ineligible eligible a public or private placement of legal commitment through court proceedings ineligible an institution operated for the treatment of mental diseases or tuberculosis ineligible a medical institution to receive medical care, such as a hospital eligible a private community facility such as a battered women’s or homeless shelter eligible an intermediate care facility for the mentally retarded (nursing home unit) even if located on the premises of a public institution eligible a private licensed group home or personal care home licensed as a CCSP provider eligible a private child care institution that provides 24-hour non-secure custodial care, such as a children’s home Consider the child an AU of one. Budget any money received by the facility for the child as income to the child. If the parents provide money, allow the $50 child support deduction. eligible an attention home operated by the DJJ eligible a contract home operated by the DJJ eligible a family foster home approved by DFCS or DJJ, Families First, Inc., United Methodist Children’s Home, Georgia Baptist Children’s Home (Palmetto) can use any other public or private agency which DFCS may approve for placement eligible a licensed private emergency shelter eligible an institution or foster care home in the state of Georgia placed by another state’s agency The child is IV-E eligible and receiving IV-E per diem in placement in Georgia. ineligible eligible Outdoor therapeutic program/outdoor therapeutic residential wilderness program. eligible

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Presumptive Eligibility Medical Assistance Effective Date: July 2024 Chapter: 2050 Policy Number: 2067 Previous MT Number(s): MT 69 Updated or Reviewed in MT: MT-72

Presumptive Eligibility (PE) Medical Assistance allows Qualified Providers (QP) and Qualified Hospitals (QH) authorized by the Department of Community Health (DCH), to make temporary determinations of Medical Assistance eligibility for applicants whose statement of net BG income is less than the appropriate FPL for the Class of Assistance (COA) requested. PE continues while a formal determination of eligibility for ongoing and/or retroactive Medical Assistance is pending with the Division of Family and Children Services (DFCS) office.

PE Medical Assistance provides outpatient prenatal care to pregnant women during the period that a formal Medical Assistance application pends with DFCS. All Medical Assistance services given by any participating Medical Assistance provider are covered during the presumptive period with exceptions of inpatient hospital and delivery services.

Hospital Presumptive Eligibility (HPE) covers all Medical Assistance related services that are covered by the specific COA requested.

Emergency Medical Assistance (EMA) cannot be completed in the Presumptive Eligibility process.

Hospital Presumptive Eligibility may be determined for the following groups:

Pregnant Women

Parent/Caretaker with Child(ren) under age 19

Child(ren) under 19

Former Foster Care Children

Women in treatment for Breast or Cervical Cancer (WHM)

The PE Medical Assistance eligibility period begins on the date the PE application is approved and ends when DFCS determines eligibility or ineligibility, but no later than at the end of the month following the month of the PE approval. (Ex. PE application approved 4/5/24 which begins coverage 4/5/24 through 5/31/24.)

The QP or QH issues temporary Medical Assistance certificates and Notice of Action (Approval/Denial) to applicants. If the applicant is approved for PE Medical Assistance, a plastic card is sent. The applicant should receive this within 7 to 10 business days. If the plastic card is not received, lost or stolen, the member must contact the Member Contact Center at 1-866-211-0950.

DFCS cannot process applications for PE or issue eligibility forms for PE.

Potential Qualified Providers include the Department of Public Health, federally funded health centers, primary care centers receiving migrant funding and/or homeless funding, hospital outpatient clinics and hospital-based special prenatal clinics.

As of July 1, 2011, Public Health became the Department of Public Health and is now a Qualified Provider.

The QP or QH determines eligibility for PE Medical Assistance based on the applicant’s pregnancy statement (Pregnant Women), certificate of diagnosis (Women’s Health), the net income of the budget group (BG), citizenship or immigrations status and residency. The QP or QH conducts a face-to-face (FTF) interview with the applicant and performs the following functions:

Screens the applicant in GAMMIS to see if he/she is already active on Medical Assistance. If a woman is already active on Medical Assistance (except Planning for Health Babies®(P4HB)) DO NOT complete a PE application. (See Note below.)

Accepts the applicant’s statement of net income and obtains adequate information from the applicant to complete the following forms: (See Note below.) Form 632, Pregnant Women Presumptive Eligibility application Form 632H Qualified Hospital Presumptive Eligibility application Form 632W, Women’s Health Presumptive Eligibility application Form 216, Declaration of Citizenship/Immigration Status Form 5460, HIPPA Notice of Privacy Practices Form 94A, Single Streamlined Medical Assistance application Form 94, Medical Assistance application (Women’s Health only)

Determines if the applicant meets eligibility criteria for PE Medicaid.

QP forwards the PE Packet to DFCS within five business days of the PE application date.

QH forward the PE Packet to DCH within five business days of the PE application date.

If the QP or QH determines that the applicant is eligible for PE Medicaid, the QP or QH completes the determination process as follows:

provides the applicant with a Temporary Medical Assistance Certificate and form 634, 634H, 634W – Notice of Action (Approval)

provides the applicant with the Quick Guide on Presumptive Eligibility Medical Assistance, Quick Guide on Presumptive Eligibility for Pregnant Women or Quick Guide on Women’s Health Medical Assistance

informs the applicant of the PE Medical Assistance period and covered services

informs the applicant about P4HB

QP forwards the PE Packet to DFCS within five business days of the PE application date

QH forwards the PE Packet to DCH within five business days of the PE application date

If the QP or QH determines that the applicant is ineligible for PE Medical Assistance, the QP or QH completes the determination process as follows:

informs the applicant that he/she is not eligible and provides him/her with the form 634, 634H or 634W – Notice of Action (Denial)

advises the applicant that if his/her circumstances change, he/she may have another determination of PE Medical Assistance completed by a QP or QH

informs the applicant that his/her application for ongoing and/or retroactive Medical Assistance will be forwarded to DFCS for a formal determination of eligibility

A PE application cannot be completed on an already active Medical Assistance member. Qualified Providers and Qualified Hospitals are unable to update pregnancy information in GAMMIS on active Medical Assistance members. If the applicant is pregnant and actively receiving Women’s Health, inform member to report pregnancy to their caseworker. If the applicant is actively SSI, QH/QP should complete the SSI Pregnant Women Update form and send to DCH by email at pecorrections@dch.ga.gov . All other active members need to contact DFCS at 1-877- 423-4746 or submit a Change Report via Gateway “Report My Change” to report their pregnancy.

Form 216 is not required when Forms 632, 632H, or 632W are used as the language is included.

For Women’s Health, a certificate of diagnosis is required at the time of application.

The Temporary Medical Assistance Certificate and the Notice of Action-Approval will serve as proof of eligibility.

The PE Packet being sent to DFCS consists of the following:

PE Application (Form 632, 632H, or 632W)

Notice of Action (Form 634, 634H or 634W) and Temporary Medical Assistance Certificate

Third Party Liability Questionnaire (DMA 285)

Single Streamlined Medical Assistance application (94A) or Medical Assistance application (94 - Women’s Health Only)

Certificate of Diagnosis (Women’s Health only)

Any documentation the applicant provides

To ensure that applications for pregnant women are processed within the 10-day standard of promptness, the local QP(s) should contact DFCS to discuss procedure for forwarding PE Packets to DFCS daily. All other COAs processed as Hospital Presumptive are subject to a 45-day standard of promptness.

Upon receipt of the PE Medicaid packet, complete a formal determination for Medical Assistance eligibility for the applicant and any other individuals for whom Medical Assistance is requested.

The application date is the date the applicant applies for benefits with the QP or QH and signs the 94 or 94a. Process the 94 or 94A application using the appropriate COA. Refer to Section 2162 Parent/Caretaker with Child(ren) , Section 2182 Children Under 19 , 2184 Pregnant Women , Section 2198 Women’s Health and Section 2819 Former Foster Care .

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Special Considerations Effective Date: December 2019 Chapter: 2050 Policy Number: 2068 Previous MT Number(s): MT 06 Updated or Reviewed in MT: MT-57

DFCS workers are outstationed at certain public health centers, disproportionate share or public hospitals and federally funded health centers to expedite the processing of applications for Medicaid. These workers process the Medicaid applications as if taken at the DFCS office.

Medicaid applications are taken at sites other than DFCS by the facility’s personnel. The facility workers are trained by DFCS to accept applications and conduct interviews.

During the interview at a non-DFCS site, the facility interviewer documents the information, signs and dates the form and forwards it to DFCS.

The DFCS worker reviews the application and interview information and conducts follow-up contact with the applicant, if necessary, either by telephone or mail.

Follow the steps below for applications received at approved facilities:

Step 1 Review the application for all points of eligibility. If additional information is required, contact the A/R by telephone or mail. Follow-up is generally not required for Presumptive Eligibility applications, which contain all information required to determine eligibility. Step 2 Mail required Forms DMA-285, 297A and 138. Step 3 Determine eligibility and notify the A/R of the decision. The application date is the date the non-DFCS facility received the signed application from the A/R. The application date for applications received from private medical facilities is the date the application is received by DFCS.

An individual who is currently receiving Medicaid in another state but has moved to Georgia may file an application. Notify the previous state that the applicant has moved to Georgia, and determine eligibility for Medicaid. Do not delay the disposition of the Medicaid application while waiting for the previous state to terminate benefits.

An individual may receive Medicaid in both states the month that s/he moves to Georgia.

An application may be filed for medical services received as a Georgia resident even if the individual subsequently moved out of state.

Complete all necessary forms. Forms can be mailed to the applicant.

Determine eligibility using the appropriate Class of Assistance (COA). Refer to 2053 Retroactive Medicaid .

If eligible, send notification of the decision and certification of Medicaid eligibility.

Refer the A/R to the previous state for application and eligibility processing.

Offer assistance in contacting the other state’s agency if the A/R is unable to do so.

Accept an application on behalf of a deceased individual by a relative or other responsible party who can provide sufficient information for an eligibility determination.

Determine eligibility based on circumstances that existed in the month(s) prior to the individual’s death that Medicaid coverage is requested. Refer to 2053 Retroactive Medicaid .

The months are limited to the application month and three months prior to the application.

Accept an application and determine eligibility if the A/R meets all eligibility requirements.

The eligibility determination is based on actual circumstances of the month of pregnancy termination and any of the three months prior to the application month. Determine eligibility under Family Medicaid Medically Needy if the BG is over the RSM income level.

If eligibility is determined for any month of the pregnancy, eligibility continues through the remainder of the pregnancy and through the 60-day postpartum transition period. Refer to 2184 Pregnant Women .

Accept applications from individuals outside the state who express the intent to move to Georgia. Deny the application because the state residency is not met. Instruct the applicant to re-apply when s/he moves to Georgia.

Complete the application process in the county in which the application was received if an applicant moves to another county prior to approval or denial of the application.

Transfer an approved case to the appropriate county after eligibility is determined and the A/R is notified of the decision.

Inform the applicant of his/her right to file the application and explain that the application will be faxed or mailed to the county of residence

AND

Inform the applicant of his/her option to take the application to the county of residence him/herself.

The application must be faxed or mailed by the agency the same day if the applicant requests the agency send the application. The date of application is the date the application was first filed by the applicant in any county.

If the applicant chooses to take the application to the county of residence, the date of application is the date the applicant presents the application to the county of residence.

Forward the application to the county of residence.

The date of application is the date the application is first received by any county in the state.

Inform the applicant that s/he is required to report within 10 days any change that occurs during the application process.

Take action on the reported change during the application process, allowing the applicant sufficient time to provide any information and/or verification that may be required.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Express Lane Eligibility Effective Date: May 2026 Chapter: 2050 Policy Number: 2069 Previous MT Number(s): MT 74 Updated or Reviewed in MT: MT 79

Express Lane Eligibility (ELE) is an enrollment strategy which begins with a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance to Needy Families (TANF), Childcare (CC), Women Infants & Children (WIC), or Refugee Cash Assistance (RCA) case used to make an ELE determination for a child(ren)'s potential Medicaid eligibility and ends with notification to the Assistance Unit (AU) of its eligibility status.

The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), Public Law 111-3 includes many provisions designed to give states some tools which may be used to effectively enroll eligible children in Medical Assistance. Section 203 of CHIPRA allows states to rely on the findings from an entity designated by the state as an “Express Lane agency” to determine whether a child satisfies one or more factors of eligibility for Medical Assistance. Such agencies are identified by the state Medicaid agency as being capable of making a finding regarding one or more programmatic eligibility requirements using information the agencies are already collecting. “Express Lane agencies” are public agencies which would include the following:

Agencies that determine eligibility for assistance for any of the following programs or under any of the following authorities: The Temporary Assistance for Needy Families (TANF) program funded under part A of title IV of the Social Security Act A State program funded under title IV-D of the Act (Child Support Enforcement) The State Medicaid or PCK program The Supplemental Nutrition Assistance Program (SNAP) (formerly Food Stamps) The Richard B. Russell National School Lunch Act (School Lunch programs) The Child Nutrition Act of 1966 (the Special Supplemental Nutrition Program for Women, Infants, and Children, or “WIC”) The United States Housing Act of 1937 Head Start Child Care under the Child Care and Development Block Grant Act of 1990 Homeless Assistance under the Stewart B. McKinney Homeless Assistance Act The Native American Housing Assistance and Self-Determination Act of 1996

Another State-specified governmental agency that has fiscal liability or legal responsibility for the accuracy of the eligibility determination findings relied on by the State.

A public agency that is subject to an interagency agreement limiting the disclosure and use of your information disclosed for purposes of determining eligibility for Medical Assistance .

The State Medical Assistance agency remains responsible for making the ultimate determination of eligibility. The Medical Assistance programs may apply the ELE option to children up to age 19.

Children (newborn through the month a child turns 19) who are active and receiving benefits on a SNAP, TANF, CC, WIC, or RCA case can have Medical Assistance eligibility determined according to ELE criteria as set forth in the Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009. The Division of Family and Children Services (DFCS) agency will utilize information collected when an application/renewal/change is completed by SNAP, TANF, CC, WIC, or RCA eligibility workers for services to determine eligibility. This data includes, but is not limited to all demographic data, proof of income, and household size.

If an application/renewal/change is received for a child younger than 19 years old, information provided by the family on that application/renewal/change or otherwise collected for the SNAP, TANF, CC, WIC, or RCA eligibility determination is used by the DFCS agency to determine most factors of Medical Assistance eligibility. During eligibility determinations, the DFCS agency will advise SNAP, TANF, CC, WIC, or RCA applicants/recipients that the information provided for the SNAP, TANF, CC, WIC, or RCA application/renewal/change will be shared with the DFCS agency for determining the children’s Medical Assistance eligibility, unless the individual chooses to opt-out on the initial application/renewal/change document or verbally during the SNAP, TANF, CC, WIC, or RCA interview.

DFCS should ensure that the child is not already enrolled in Medicaid (including SSI), PCK, or Medicare prior to an ELE determination. If a child(ren) under 19 Medical Assistance application is received and there is no active SNAP, TANF, CC, WIC, or RCA case, then an ELE determination cannot be completed.

The DFCS agency will use the SNAP, TANF, CC, WIC, or RCA income findings, calculated based on the specific program’s eligibility policies (income exclusions, disregards, household composition, deeming, etc.) to determine income eligibility for Medical Assistance. DFCS will use other information collected by the SNAP, TANF, CC, WIC, or RCA program on the application/renewal or through its verification processes to determine most other factors of Medical Assistance eligibility (e.g., verification of citizenship, State residency). Any SNAP, TANF, CC, WIC, or RCA eligible children that meet the specific program’s citizenship requirements, must also meet Medical Assistance citizenship requirements. A Reasonable Opportunity Period (ROP) for citizenship is allowed for ELE determinations. Refer to Section 2215-Citizenship/Immigration/Identity .

For Medical Assistance ELE determinations, DFCS should compare household income to the highest Medicaid income applicable to a child (0-19) which will be equal to 235% FPL. If household income is over 235% FPL but at or below 247% FPL, the child should be evaluated for ELE-PCK.

If a child is found eligible for PCK from the ELE determination, DFCS must provide notice that the child may qualify for Medicaid and/or lower premiums if evaluated using the regular eligibility determination and provide an avenue on how to request a full eligibility determination. A separate application is not required. Refer to Section 2194 - Peachcare for Kids® for ELE PCK premium amounts.

Children with third-party liability (TPL) are not eligible for PCK.

If the child’s Medical Assistance eligibility cannot be determined based on the processes used for ELE (e.g., the child is over income for PCK using the “Express Lane” agency’s income finding), a full eligibility determination must be conducted using the regular Medical Assistance processes. The income findings from the “Express Lane agency” should not be used, and additional information or verification should be requested from the family as necessary.

If a full determination is conducted based on a request or denial for any potential ELE applicant, the application is no longer considered ELE.

For ELE applications, retroactive months requested should follow the regular eligibility determination process.

It is the expectation that the ELE determination will be completed at the same time as the SNAP, TANF, CC, WIC, or RCA application/renewal but no longer than 45 days from the date ELE was requested.

If a client submits a Change Request for an already active SNAP, TANF, CC, WIC, or RCA case with a child younger than 19 years old, determine eligibility according to ELE criteria.

If the client has an approved ELE determination and would like to opt out of the ELE process and have a full Medical Assistance determination made, the client can call the DFCS call center at 1-877-423-4746 or complete the opt-out statement and drop off at their local DFCS office or upload online at gateway.ga.gov at any time.

Follow the steps below to determine Medical Assistance using the ELE application process:

Step 1 Accept SNAP, TANF, CC, WIC, or RCA application/renewal/change request for children under 19 years of age submitted through Gateway Customer Portal or other acceptable application/renewal forms. Step 2 Determine ELE eligibility for CU19 or PCK based on the information collected at SNAP, TANF, CC, WIC, or RCA application/renewal/change including household size, residency, income, and citizenship. Children must meet Medical Assistance citizenship requirements Step 3 Approve the case using the appropriate COA (CU19/PCK) if the applicant meets all eligibility criteria. If the child’s Medical Assistance eligibility cannot be determined based on the processes used for ELE (e.g., the child is over income for PCK using the express lane agency’s income finding), a full eligibility determination must be conducted using the regular Medical Assistance processes. The income findings from the express lane agency should not be used, and income eligibility should be determined using Medical Assistance policies and procedures. A full determination follows the regular MAGI eligibility determination process. Step 4 Notify the AU of the eligibility determination.

Reasonable Opportunity Period (ROP) is allowed for ELE determinations.

Child(ren) eligible for PeachCare for Kids® may be subject to a premium. Send a determination notice to advise client to report any changes and the ability to opt out of ELE at any time.

If SNAP, TANF, CC, WIC, or RCA closes due to information not provided from VCL, the ELE case will remain active until the end of the ELE POE.

If retroactive months are requested and case is approved for ELE, the retroactive months need to follow the regular MAGI eligibility determination process.

If SNAP, TANF, CC, WIC, or RCA is active with at least one ongoing month at the end of the ELE renewal POE, the ELE case will be automatically renewed using the ELE process.

If SNAP, TANF, CC, WIC, or RCA is not active at the end of the ELE renewal POE, the ELE case would no longer be considered ELE, and renewal must follow the regular MAGI eligibility determination process.

Administrative renewals should not be completed for Medicaid cases whose Medicaid eligibility has been determined using Express Lane Eligibility (ELE).

Gateway should not allow an ELE determination if an individual member is currently receiving Medical Assistance including:

SSI or Medicare for ELE-CU19

SSI, Medicare or TPL for ELE-PCK.

ELE determinations do not apply to:

Expedited SNAP applications that are not approved for a full period of eligibility (POE)

Transitional SNAP recipients

Disaster Supplemental Nutrition Assistance Program (DSNAP) recipients

Disaster Temporary Assistance for Needy Families (DTANF) recipients

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: ABD Medicaid Classes of Assistance Overview Effective Date: November 2023 Chapter: 2100 Policy Number: 2101 Previous MT Number(s): MT 58 Updated or Reviewed in MT: MT-71

An individual must meet the requirements specified under a particular class of assistance (COA) in order to be determined eligible for ABD Medicaid.

ABD Medicaid COAs are divided into the following two types:

FBR (Federal Benefit Rate) – COAs that use the SSI FBR to determine income eligibility.

Non FBR – COAs that use an income limit other than the FBR to determine income eligibility.

The FBR COAs consist of the following:

SSI Medicaid

Pickle (PL 94-566)

Disabled Adult Child (PL 99-643)

Disabled Widow(er) Age 50-64

Widow(er) 60-64 (PL 100-203)

Widow(er) 1983 (PL 99-272) ( No longer approve these COAs )

Protected Medicaid 1972 (PL 92-603) ( No longer approve these COAs )

Former SSI Disabled Child

The Non-FBR COAs consist of the following:

Elderly and Disabled Waiver Program (EDWP) formerly known as Community Care Services Program (CCSP)

New Options Waiver (NOW)

Comprehensive Supports Waiver Program (COMP)

TEFRA/Katie Beckett

Hospice

Hospital

Independent Care Waiver Program (ICWP)

Nursing Home (NH)

ABD Medically Needy (AMN)

Qualified Disabled Working Individuals (QDWI)

Q Track: Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Qualifying Individual 1 (QI-1) QMB eligibility for persons receiving SSI is discussed in 2143 Qualified Medicare Beneficiaries .

Refer to Chapter 2050, Application Processing, for a discussion of other Medicaid coverage, including the following:

2054 Emergency Medical Assistance

Retroactive Medicaid, including three months prior and intervening months, Section 2053

2055 Sponsored Aliens

Refer to Chapter 2900, Referrals, for other sources of medical assistance.

Follow the steps below to determine ABD Medicaid eligibility under a specific COA.

Step 1 Accept the individual’s ABD Medicaid application and register the application on the system. Step 2 Screen each A/R to determine potential SSI eligibility, Family Medicaid, PeachCare for Kids® and/or TANF eligibility. Refer to Chapter 2500, ABD Financial Responsibility and Budgeting, to determine which SSI trial budget to complete (Individual, Couple or Spouse to Spouse Deeming). Use the FBR as the income limit when completing the SSI trial budget. Step 3 Refer the A/R to the appropriate worker if the A/R appears to be eligible for Family Medicaid and/or TANF and wishes to file an application for either. The A/R’s application for assistance is protected indefinitely. Refer the A/R to SSA to file an SSI application if his/her Federal Countable Income (FCI) is less than the appropriate Federal Benefit Rate (FBR) unless one of the following situations exist: The A/R requests coverage for any of the 3 months prior to the SSI or ABD Medicaid Application Month. The A/R is ineligible due to the deemed income or resources of his/her spouse or parents. The A/R dies prior to applying for SSI. The A/R is ineligible for Family Medicaid/SSI due to excess resources. The A/R has Medicare or other insurance that is expected to pay (or pays) more than 50% of medical expenses, and the A/R is in a public or private hospital or nursing home. Step 4 Obtain information necessary to process application. Request verification, if necessary. Step 5 Determine the COA most advantageous to the A/R. Explain the advantages of each COA if the A/R is potentially eligible under more than one COA and allow the A/R to choose the COA. Step 6 Determine basic eligibility. Refer to Chapter 2200, Basic Eligibility Criteria. Step 7 Determine financial eligibility. Refer to PROCEDURES under the specific section on each COA. Step 8 If the A/R is eligible under the COA currently being used to determine eligibility, approve ABD Medicaid on the system. If the A/R is ineligible under the COA currently being used to determine eligibility, complete a CMD. Refer to 2052 Continuing Medicaid Determination .

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Supplemental Security Income (SSI) Medicaid Effective Date: November 2023 Chapter: 2100 Policy Number: 2111 Previous MT Number(s): MT 58 Updated or Reviewed in MT: MT-71

Supplemental Security Income (SSI) is a direct monetary payment program administered by the Social Security Administration (SSA) under Title XVI of the Social Security Act. SSI Medicaid is used by DFCS as a class of assistance (COA) for determining sponsored alien and retroactive Medicaid eligibility.

Georgia SSI recipients are automatically eligible for Medicaid for any month in which they receive a check except when they refuse to assign TPR. Refer to 2230 Third Party Liability .

To be eligible under the SSI Medicaid COA, the A/R must meet the following conditions:

The A/R has applied for SSI or ABD Medicaid.

The A/R requests ABD Medicaid coverage for a month(s) for which s/he is not eligible to receive an SSI payment, such as the following: two months prior to an SSI approval (for the third prior month refer to 2053 Retroactive Medicaid ) three months prior to an SSI denial three months prior to an ABD Medicaid application the months related to an SSI application for which the applicant is not financially eligible for an SSI payment the months in which the income of a sponsor renders an alien ineligible for SSI.

The A/R meets all basic and financial eligibility criteria.

Length of Stay (LOS) and Level of Care (LOC) are not requirements for this COA.

Do not determine eligibility under the SSI COA for any month covered by an SSI application (the three prior months, the month of SSI application and ongoing) while the SSI application is pending. Refer to 2053 Retroactive Medicaid .

Effective for SSI applications filed on or after August 22, 1996, the first month of SSI payment is the first month following the date the application is filed, or the first month following the month the individual becomes eligible for SSI, whichever is later. For approved or denied SSI applications, the three prior months are the three months preceding the month of SSI application.

Do not use the SSI Medicaid COA to determine eligibility for the third month prior to an SSI approval. Refer to 2053 Retroactive Medicaid for instructions on processing eligibility for SSI prior months.

See 2579 SSI 1619 Individuals for SSI Terminations of SSI 1619 Individuals.

Follow the steps below to determine Medicaid eligibility under the SSI Medicaid COA.

Step 1 Accept the A/R’s request for retroactive Medicaid. A signed application is not required for this COA since an application has been filed with the Social Security Administration (SSA). Step 2 Obtain information necessary to process the requested months of eligibility. Step 3 Determine basic eligibility criteria. Refer to Chapter 2200, Basic Eligibility Criteria. Step 4 Determine financial eligibility using the current SSI income and resource limits. Refer to Chapter 2500, ABD Financial Responsibility and Budgeting, to determine the following: Whose income and resources to consider Which SSI income/resource limits (individual or couple) to use Which eligibility budget to complete. Step 5 Approve Medicaid using the SSI Medicaid COA for any retroactive month in which the A/R meets all eligibility criteria. Do not approve SSI COA for the third month prior to an SSI approval. Refer to 2053 Retroactive Medicaid for the appropriate COA and procedures on completing prior months for SSI applications.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: PICKLE (Public Law 94-566) Effective Date: February 2020 Chapter: 2100 Policy Number: 2113 Previous MT Number(s): MT 10 Updated or Reviewed in MT: MT-58

Pickle (PL 94-566) is a class of assistance (COA) that provides for an individual or couple who correctly received RSDI and SSI or a Mandatory State Supplement (MSS) concurrently and became ineligible for SSI or MSS for any reason but is currently ineligible for SSI because of RSDI COLAs.

To be eligible under the Pickle COA, the A/R must meet the following conditions:

The A/R previously and correctly received RSDI and SSI or MSS concurrently.

The A/R’s SSI or MSS was terminated after 4/77 for any reason.

The A/R is eligible for SSI or MSS if the RSDI COLAs received by the A/R and/or his/her spouse since the A/R last received SSI or MSS are disregarded.

The A/R meets all basic and financial eligibility criteria.

In couple situations, only one spouse needs to have received RSDI and SSI or MSS concurrently. However, each individual must have previously received SSI or MSS in order to establish eligibility under this COA. In order for one member of the couple to be exempt from the requirement of having received SSI and RSDI concurrently, the couple must have been married at the time of the loss of SSI eligibility.

Length of Stay (LOS) and Level of Care (LOC) are not requirements for this COA.

Individuals who receive an SSI and RSDI payment in the last month of the waiting period on initial entitlement to RSDI disability benefits are not considered to have received SSI and RSDI concurrently.

Follow the steps below to determine Medicaid eligibility under the Pickle COA.

Step 1 Accept the A/R’s Medicaid Application. Step 2 Obtain verification from SSA to verify the following: The date SSI benefits were terminated. The current amount of the A/R’s and/or his/her spouse’s RSDI. The amounts of all RSDI COLAs the A/R and/or his/her spouse have received since SSI was terminated. Step 3 Determine all basic eligibility criteria except LOS and LOC. Refer to Section 2200, Basic Eligibility Criteria. Step 4 Determine all basic eligibility using the current SSI income and resource limits. Refer to Section 2500, ABD Financial Responsibility and Budgeting, to determine the following: Whose income and resources to consider. Which SSI income and resource limit (individual or couple) to use Which eligibility budget to complete. Step 5 Determine the A/R’s countable income by disregarding the following amounts of RSDI income. The COLA that caused SSI termination OR The first COLA received after SSI was terminated for a reason other than receipt of a COLA, such as a resource ineligibility AND All subsequent COLAs. The COLAs of the A/R (individual or couple) and the A/R’s ineligible spouse can be disregarded in determining eligibility under the Pickle COA. Step 6 Approve Medicaid on the system using the Pickle COA if the A/R meets all the above eligibility criteria, including retroactive months if needed. Do not approve Medicaid using the Pickle COA for any month for which the A/R was eligible for and received an SSI payment.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Disabled Adult Child (Public Law 99-643) Effective Date: February 2020 Chapter: 2100 Policy Number: 2115 Previous MT Number(s): MT 15 Updated or Reviewed in MT: MT-58

Disabled Adult Child (PL 99-643) is a class of assistance (COA) that provides Medicaid for an individual age 18 or over who had his/her SSI terminated on or after 7/1/87 because of entitlement to or an increase in RSDI income received as a disabled adult child.

To be eligible under the Disabled Adult Child COA, the A/R must meet the following conditions:

The A/R is currently receiving RSDI as a disabled adult child.

The A/R previously received SSI that was terminated on or after 7/1/87 because of an increase in or initial entitlement to RSDI as a disabled adult child. The increase or initial entitlement must have been on RSDI (Title II) income, not RRR or other income

The A/R is eligible for SSI if the initial entitlement to RSDI, any increase(s) in RSDI and/or RSDI COLAs received since the A/R last received SSI are disregarded.

The A/R meets all basic and financial eligibility criteria.

Length of Stay (LOS) and Level of Care (LOC) are not requirements for this COA.

The RSDI claim number will end with a beneficiary identification code (BIC) that includes C if the A/R receives RSDI as a disabled adult child.

Approve Medicaid on the system using the Disabled Adult child COA if the A/R meets all the above eligibility criteria, including retroactive months if needed.

Do not approve Medicaid using the Disabled Adult Child COA for any month for which the A/R was eligible for and received an SSI payment.

Follow the steps below to determine Medicaid eligibility under the Disabled Adult Child COA.

Step 1 Accept the A/R’s Medicaid application. Step 2 Conduct an interview. Step 3 Obtain verification from SSA to verify the following: The date SSI benefits were terminated. The current amount of the A/R’s RSDI disabled adult child benefit. The amounts of the RSDI initial entitlement, increase or COLA that caused SSI termination and all RSDI increases received since SSI was terminated. Step 4 Determine all basic eligibility criteria except LOS and LOC. Refer to Chapter 2200, Basic Eligibility Criteria. Step 5 Determine financial eligibility using the current SSI income and resource limits. Refer to Chapter 2500, ABD Financial Responsibility and Budgeting to determine the following: Whose income and resources to consider Which SSI income and resource limit (individual or couple) to use Which eligibility budget to complete. Step 6 Determine the A/R’s countable income by disregarding the following amounts of RSDI income: The initial entitlement to or increase in RSDI as a disabled adult child or an increase in RSDI income that caused SSI termination OR The RSDI disabled adult child COLA that caused SSI termination AND All subsequent increases in RSDI. This would include COLAs as well as RSDI increases due to a change in the parents' circumstances, such as retirement and/or death. The only RSDI increase that would not be subject to disregard would be an increase due to the DAC’s own work record. Step 7 The RSDI claim number will end with a beneficiary identification code (BIC) that includes C if the A/R receives RSDI as a disabled adult child. Approve Medicaid on the system using the Disabled Adult child COA if the A/R meets all the above eligibility criteria, including retroactive months if needed. Do not approve Medicaid using the Disabled Adult Child COA for any month for which the A/R was eligible for and received an SSI payment.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Former SSI-Disabled Child Effective Date: December 2022 Chapter: 2100 Policy Number: 2116 Previous MT Number(s): MT 64 Updated or Reviewed in MT: MT-68

The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 changed the definition of disability for children. As a result, a number of children were terminated from SSI. The Balanced budget Act of 1997 mandated that for any child who became ineligible for SSI due to the new definition of disability, the State must redetermine Medicaid eligibility using the previous definition of disability. The Act further specified that the disability status of the child must be protected as long as the child remains eligible for SSI but for the change in definition of disability.

To be eligible under the Former SSI-Disabled Child COA, the A/R must meet the following conditions:

The A/R was receiving SSI as a disabled child on August 22, 1996, and was terminated as a result of SSA’s new definition of disability. This includes those SSI A/R’s who, as of August 22, 1996: The A/R was receiving SSI as a disabled child on August 22, 1996, and was terminated as a result of SSA’s new definition of disability. This includes those SSI A/R’s who, as of August 22, 1996: were in current pay status; or received a favorable or partially favorable administrative decision from SSA; or were terminated due to non-cooperation with the disability redetermination process of SSA; or had a Zebley appeal pending.

The A/R would be eligible for SSI but for the passage of the new disability decision.

The A/R continues to meet all basic and financial eligibility criteria for SSI.

Length of Stay (LOS) and Level of Care (LOC) are not requirements for this COA.

Applications are no longer reviewed under this COA.

Follow the steps below to determine Medicaid eligibility under the Former SSI-Disabled Child COA:

Step 1 Use the DMA generated report entitled SSI to Disabled Children (Section 4913) or accept an application from any A/R contacting DFCS whose name did not appear on said report. Refer to Section 2752, Continuing Medicaid Determination Reports, for instructions on processing the report. Step 2 Screen the A/R in the system to determine if they have an active Medicaid case with DFCS. Step 3 For A/R’s not appearing on the SSI to Disabled Children (Section 4913) Report, verify that the child was receiving SSI on August 22, 1996, and that the SSI was terminated due to the new definition of disability. For children whose names do appear on the report, accept the report as verification for this step. Step 4 Using SDX, BENDEX and any other available information, register the case on the system. Prior receipt of SSI is prima facie evidence of disability until the first annual review for all A/R’s who were terminated SSI as a result of the new disability decision. Step 5 Approve Medicaid, including retroactive months if requested, on the system within 10 days of receipt of the list or application unless available information determines the A/R to be ineligible. If the A/R is ineligible, see Special Considerations below. Notify DMA via the form on the GoMail bulletin board entitled Medicaid Forms if the A/R is ineligible for any COA.

The county must complete a full review of eligibility within 12 months of approval or when a change is reported, whichever is earlier.

At the first review of eligibility, submit a disability request to SMEU, specifying that the A/R is a Former SSI-Disabled Child. Redetermine all other points of eligibility using current SSI eligibility criteria in order to establish continued ongoing eligibility.

If the A/R was terminated from SSI for any reason other than disability, the A/R is NOT eligible for Medicaid under this COA. Complete a CMD. Refer for TANF or Family Medicaid if appropriate. Only request a SMEU decision for another ABD COA if the SSI has been terminated for more than 12 months.

If an A/R is approved for but later becomes ineligible for Medicaid under the Former SSI-Disabled child COA for any reason other than disability, the child’s disability status remains protected. The child can become eligible again under this COA.

There is not an aid category for this COA in GAMMIS.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Disabled Widow(er) Effective Date: December 2022 Chapter: 2100 Policy Number: 2117 Previous MT Number(s): MT 58 Updated or Reviewed in MT: MT-68

The Disabled Widow(er) class of assistance (COA) provides Medicaid for an individual whose SSI was terminated because of his/her entitlement to an RSDI disabled widow(er) benefit.

To be eligible under the Disabled Widow(er) COA the A/R must meet the following conditions:

The A/R is a disabled widow(er) or a disabled surviving divorced spouse between the ages of 50-59

The A/R is currently receiving RSDI as a disabled widow(er)/disabled surviving divorced spouse.

The A/R is currently ineligible for Medicare Part A coverage.

The A/R previously received SSI or a Mandatory State Supplement (MSS) that was terminated on or after 1/1/91 because of his/her initial entitlement to RSDI as a disabled widow(er)/disabled surviving divorced spouse.

The A/R is eligible for SSI or MSS if the initial entitlement to RSDI as a disabled widow(er) and all subsequent COLAs are disregarded.

The A/R meets all basic and financial eligibility criteria.

Length of Stay (LOS) and Level of Care (LOC) are NOT requirements for this COA.

A disabled Widow(er) is an individual who applies for RSDI between the ages of 50-59 and is determined to meet RSDI disability criteria.

A widow(er) who applies for RSDI at age 60 or older can receive RSDI without meeting disability requirements. SSA will accept a disability application on these individuals after age 60 only for the purpose of establishing Medicare entitlement. These individuals are not eligible for Medicaid under the Disabled Widow(er) COA. Consider eligibility under all other COAs, including Widow(er) Age 60 to 64 COA.

Disabled widow(er)s whose SSI was terminated on or after 1/1/91 are allowed to count previous months of SSI eligibility toward the 24-month waiting period for Medicare entitlement.

Follow the steps below to determine Medicaid eligibility under the Disabled Widow(er) COA:

Step 1 Accept the A/R’s Medicaid application. Step 2 Obtain information required to complete the eligibility determination. Step 3 Obtain the following verification from the Social Security Administration: The date SSI/MSS benefits were terminated The current amount of the A/R’s RSDI Disabled Widow(er) benefit The amounts of the RSDI initial entitlement that caused SSI/MSS termination and all COLAs received since SSI/MSS was terminated The A/R’s current ineligibility for Medicare Part A coverage Step 4 Determine all basic eligibility criteria except LOS and LOC. Refer to Chapter 2200, Basic Eligibility Criteria. Step 5 Determine financial eligibility using the current SSI income and resource limits. Refer to Chapter 2500, ABD Financial Responsibility and Budgeting, to determine the following: Whose income and resources to consider Which SSI income and resource limit (individual or couple) to use Which eligibility budget to complete Determine the A/R’s countable income by disregarding the following amounts of RSDI income: The initial entitlement to RSDI as a disabled widow(er) that caused SSI termination AND All subsequent COLAs The RSDI claim number will end with a beneficiary identification code (BIC) that includes “W” if the A/R receives RSDI as a disabled widow(er) or surviving divorced spouse. Step 6 Approve Medicaid under the Disabled Widow(er) COA if the A/R meets all the above eligibility criteria, including retroactive months if needed. Do NOT approve Medicaid using the Disabled Widow(er) COA for any month for which the A/R was eligible for and received an SSI payment. Step 7 Terminate Medicaid under this COA as soon as the A/R becomes entitled to Medicare Part A. Complete a CMD. Refer to 2052 Continuing Medicaid Determination .

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Disabled Widow(er) Age 60-64 (Public Law 100-203) Effective Date: February 2020 Chapter: 2100 Policy Number: 2119 Previous MT Number(s): MT 10 Updated or Reviewed in MT: MT-58

Widow(er) Age 60 – 64 (PL 100-203) is a class of assistance (COA) that provides Medicaid for a widow(er) who applies for an RSDI widow(er) benefit at age 60 or older and subsequently has his/her SSI terminated because of his/her entitlement to an RSDI widow(er) benefit.

To be eligible under the Widow(er) Age 60 – 64 COA the A/R must meet the following conditions:

The A/R is a disabled or blind widow(er) aged 60 – 64.

The A/R is currently receiving an RSDI widow(er)/surviving divorced spouse benefit.

The A/R is currently ineligible for Medicare Part A coverage.

The A/R previously received SSI that was terminated because of his/her initial entitlement to RSDI as a widow(er)/surviving divorced spouse.

The A/R is eligible for SSI if the initial entitlement to RSDI as a widow(er)/surviving divorced spouse and all subsequent COLAs are disregarded.

The A/R meets all basic and financial eligibility criteria.

Length of Stay (LOS) and Level of Care (LOC) are NOT requirements for this COA.

When the A/R becomes Medicare eligible at age 65 or after 24 months as disabled, s/he is NO longer eligible under this COA. Complete a CMD. Refer to Section 2052, Continuing Medicaid Determination.

Refer to Section 2117, Disabled Widow(er), for information on Medicare entitlement based on disability for an individual receiving an RSDI widow(er) benefit.

Follow the steps below to determine Medicaid eligibility under the Widow(er) Age 60 – 64 COA.

Step 1 Accept the A/R’s Medicaid application. Step 2 Obtain information required to complete the eligibility determination. Step 3 Verify that the A/R is age 60 – 64. Step 4 Obtain the following verification from the Social Security Administration: The date SSI benefits were terminated. The current amount of the A/R’s RSDI Widow(er) benefit. The amounts of the RSDI initial entitlement that caused SSI termination and all COLAs received since SSI was terminated The A/R’s current ineligibility for Medicare Part A coverage. Step 5 Determine all basic eligibility criteria except LOS and LOC. Refer to Chapter 2200, Basic Eligibility Criteria. Verify blindness or disability if the A/R does not have prima facie evidence of blindness or disability, such as receipt of an RSDI disability benefit. Refer to Section 2205, ABD Requirement. Step 6 Determine financial eligibility using the current SSI income and resource limits. Refer to Chapter 2500, ABD Financial Responsibility and Budgeting, to determine the following: Whose income and resources to consider. Which SSI income and resource limit (individual or couple) to use. Which eligibility budget to complete. Determine the A/R’s countable income by disregarding the following amounts of RSDI income: The initial entitlement to RSDI as a widow(er) that caused SSI termination AND All subsequent COLAs The RSDI claim number will end with a beneficiary identification code (BIC) that includes “D” if the A/R receives RSDI as a widow(er)/surviving divorced spouse. Step 7 Approve Medicaid, including prior months if needed, under the Widow(er) Age 60 - 64 COA if the A/R meets all the above eligibility criteria. Do NOT approve Medicaid using the Widow(er) Age 60-64 COA for any month for which the A/R was eligible for and received a SSI payment. Step 8 Terminate Medicaid under this COA as soon as the A/R becomes entitled to Medicare Part A. Complete a CMD. Refer to Section 2052, Continuing Medicaid Determination.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Widow(er) 1984 (Public Law 99-272) Effective Date: February 2020 Chapter: 2100 Policy Number: 2121 Previous MT Number(s): MT 10 Updated or Reviewed in MT: MT-58

Widow(er) 1984 (PL 99-272) is a class of assistance (COA) for an individual who received RSDI and SSI concurrently and became ineligible for SSI due to an adjustment in his/her RSDI disabled widow(er)'s benefit effective 1/84.

Do NOT determine initial ABD Medicaid eligibility under the Widow(er) 1984 COA on any application filed on or after 7/1/88. Complete annual reviews for continued eligibility on established cases as for any other COA.

To be eligible under the Widow(er) 1984 COA the A/R must meet the following conditions:

The A/R received RSDI and SSI in 12/83.

The A/R became entitled to and received an adjustment in his/her RSDI disabled widow(er)'s benefit effective 1/84 that caused SSI termination in the month the increased benefit was actually received.

The A/R was continuously entitled to the increased RSDI benefit from 1/84 until the increase was actually received.

The A/R is eligible for SSI if the 1/84 increase in the RSDI disabled widow(er) benefit and any subsequent COLAs are disregarded.

The A/R meets all basic and financial eligibility criteria.

Length of Stay (LOS) and Level of Care (LOC) are NOT requirements for this COA.

Applications are no longer approved under this COA.

Complete an annual review of eligibility for individuals currently eligible under the Widower 1984 COA. Refer to Section 2705, Reviews.

Use the following guidelines for completing the review:

Step 1 Obtain verification from the SSA to verify the following: The A/R’s receipt of RSDI and SSI in 12/83. The A/R’s receipt of an increased RSDI disabled widow(er)'s benefit effective 1/84. The A/R’s ineligibility for SSI the month increased benefit was actually received. The A/R’s continuous receipt of an RSDI disabled widow(er)'s benefit. The current amount of the RSDI widow(er)'s benefit and all subsequent COLAs. Step 2 Determine financial eligibility using the current SSI income and resource limits. Refer to Chapter 2500, ABD Financial Responsibility and Budgeting, to determine the following Whose income and resources to consider. Which SSI income and resource limit (individual or couple) to use. Which eligibility budget to complete. Step 3 Determine the A/R’s countable income by disregarding the following amounts of RSDI income: The 1/84 increase in the RSDI disabled widow(er)'s benefit. All subsequent COLAs. The RSDI claim number will end with a beneficiary identification code (BIC) that includes “W” if the A/R receives RSDI as a disabled widow(er)/disabled surviving divorced spouse.

Do NOT approve Medicaid using the Widow(er) 1984 COA for any month for which the A/R was eligible for and received a SSI payment.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Protected Medicaid 1972 (Public Law 92-603) Effective Date: February 2020 Chapter: 2100 Policy Number: 2123 Previous MT Number(s): MT 10 Updated or Reviewed in MT: MT-58

Protected Medicaid 1972 (PL 92-603) is a class of assistance (COA) that provides Medicaid for an individual/couple who received AABD or AFDC and RSDI concurrently in 1972 and became ineligible for AABD or AFDC because of the 20% 1972 COLA increase in RSDI.

To be eligible under the Protected Medicaid 1972 COA an A/R must meet the following conditions:

The A/R is currently receiving RSDI.

The A/R received AABD or AFDC and RSDI in 8/72.

The A/R is currently eligible for SSI if the 1972 RSDI COLA is disregarded.

The A/R meets all basic and financial eligibility criteria.

Length of Stay (LOS) and Level of Care (LOC) are NOT requirements for this COA.

Prior receipt of SSI is NOT a requirement for this COA.

Applications are no longer approved under this COA.

Follow the steps below to determine Medicaid eligibility under the Protected Medicaid 1972 COA:

Step 1 Accept the A/R’s Medicaid application. Step 2 Obtain information required to complete the eligibility determination. Step 3 Using county and state records, determine whether the A/R received AABD or AFDC in 8/72. Step 4 Obtain the following verification from the Social Security Administration: The current amount of the A/R’s RSDI benefit. The amount of the A/R’s 8/72 RSDI COLA. Step 5 Determine all basic eligibility criteria except LOS and LOC. Refer to the Chapter 2200, Basic Eligibility Criteria. Step 6 Determine financial eligibility using the current SSI income and resource limits. Refer to the Chapter 2500, ABD Financial Responsibility and Budgeting, to determine the following: Whose income and resources to consider Which SSI income and resource limit (individual or couple) to use Which eligibility budget to complete Step 7 Approved Medicaid under the Protected Medicaid 1972 COA if the A/R meets all the above eligibility criteria, including retroactive months if needed. Do not approve Medicaid under the Protected Medicaid 1972 COA for any month for which the A/R was eligible for and received an SSI payment.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Elderly Disabled Waiver Program Effective Date: December 2022 Chapter: 2100 Policy Number: 2131 Previous MT Number(s): MT 64 Updated or Reviewed in MT: MT-68

Elderly Disabled Waiver Program (EDWP) formerly known as Community Care Services Program (CCSP) is a Class of Assistance (COA) designed to provide in home and community-based services to individuals. These individuals meet the criteria for nursing home placement but choose to remain in a residential home situation.

To be eligible under the EDWP COA, an A/R must meet the following conditions:

The A/R is admitted to EDWP and receiving a waivered service(s).

The A/R resides in a residential home situation, such as his/her own home, another person’s home or a personal care home.

The A/R meets the Length of Stay (LOS) and Level of Care (LOC) eligibility criteria.

The A/R meets all other basic and financial eligibility criteria.

There is no age requirement for participation in EDWP. A client is not required to be homebound to receive EDWP services.

EDWP Medicaid recipients receive certain waivered services not normally covered by Medicaid, including the following:

Adult Day Health

Alternate Living Services (personal care home placement)

Emergency Response System

Home Health Services/Home Delivered Services

Personal Support Services

Respite Care

To maintain continuous eligibility for EDWP Medicaid, a client must receive waivered services each calendar month.

Individuals who express an interest in Elderly Disabled Waiver services are to be referred to the Area Agency on Aging for assessment. The telephone screening specialist assesses the individual’s suitability for community-based care in lieu of nursing home placement. If the individual meets the EDWP eligibility criteria, the A/R’s name is placed on the EDWP waiting list. When funds become available, the individual is referred to the Care Coordination Agency for a face-to-face assessment.

If the individual is determined eligible at the face-to-face assessment, s/he is admitted to EDWP.

The care coordinator arranges for the provision of the EDWP waivered services to the recipient.

EDWP is a budgeted program, therefore, it is limited to a certain number of clients statewide

Follow the steps below to determine ABD Medicaid eligibility under the EDWP COA.

Step 1 Accept the A/R’s Medicaid application. Step 2 Conduct an interview. Step 3 Verify that the A/R is under EDWP care coordinator and receiving waivered service(s) by receipt of the Elderly and Disabled Waiver Communicator (CCC). The CCC should indicate the beginning date of care coordination and the service date. Step 4 Determine basic eligibility, including Length of Stay (LOS) and Level of Care (LOC). Refer to the Chapter 2200, Basic Eligibility Criteria. Step 5 Determine financial eligibility. See Chapter 2500, ABD Financial Responsibility and Budgeting, for procedures on whose resources to consider and the resource limit to use in determining resource eligibility. Complete a Medicaid CAP budget to determine income eligibility. Refer to the 2510 Medicaid Cap Budgeting . If client’s income exceeds the Medicaid CAP, then client must establish a QIT in order to be determined eligible. Step 6 Determine the A/R’s cost share for EDWP services. Refer to 2559 Patient Liability / Cost Share Budgeting and 2553 Protection of Income . Step 7 Approve EDWP Medicaid if the A/R meets all the above eligibility criteria. DO NOT approve Medicaid under the EDWP class of assistance for any month earlier than the month of the service date. Step 8 Notify the A/R of case disposition and cost share. Step 9 Notify the care coordinator of the disposition and cost share by entering the care coordinator’s name and address in the system as the Authorized Representative. This will enable the care coordinator to receive system generated notices giving dates of eligibility and cost share information. Step 10 Complete a review of the case in the month in which the EDWP LOC expires as indicated in Field 45, L.O.S, of the LOC form. If a new LOC form extending the stay is received from the EDWP care coordinator, continue Medicaid eligibility under the EDWP COA. If the new LOC form stating that the LOC has NOT been extended is received from the care coordinator OR a new LOC form is not received from the EDWP care coordinator by the end of the month the LOC expires, complete a CMD. Refer to the 2052 Continuing Medicaid Determination . Notify the EDWP care coordinator of the outcome of the CMD and any change in cost share. If LOC form or CCC is not received within two weeks from the end of the approved EDWP stay, send a CCC to the care coordinator requesting information on whether the stay has been extended. If Medicaid eligibility is terminated as a result of the CMD and a new LOC form is subsequently received within 30 days of the termination date on the system, reopen the case as closed in error. If a new LOC form is received more than 30 days after the system termination date, process a new application. The month the new LOC form is signed is the earliest month for which the case can be reopened under the EDWP COA.

If an EDWP A/R temporarily enters a NH (30 days or less), they may continue as EDWP if the NH is enrolled as an EDWP provider. The NH stay would be billed as respite care. The MES would not make any changes in the system based on the temporary NH stay. Change to NH COA if the A/R remains for more than 30 days.

An EDWP recipient may elect to receive Hospice services along with EDWP. Hospice is paid directly by DCH without any Hospice information entered into DFCS' computer system. A/R should remain in EDWP COA. If A/R was in Hospice COA, switch to EDWP.

A disabled child may be eligible for a $30 SSI personal needs allowance from SSA if s/he meets the following criteria:

Is disabled

Received SSI benefits (limited to PNA) while in a medical treatment facility

Is ineligible for SSI solely because of deemed income or resources of the parents

Is currently eligible for Medicaid under one of the following COAs: TEFRA/Katie Beckett (Section 2133) EDWP (Section 2131) Is receiving services under GAPP (Section 2933)

If the child meets the above criteria, refer the parent(s) to SSA to continue the SSI $30 PNA payment and Medicaid. Continue to maintain the child under the COA above unless the child no longer meets the criteria for that program.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: New Option Waiver and Comprehensive Supports Waiver Program Effective Date: July 2024 Chapter: 2100 Policy Number: 2132 Previous MT Number(s): MT 60 Updated or Reviewed in MT: MT-72

New Options Waiver (NOW) and Comprehensive Supports Waiver Program (COMP) are classes of assistance (COA) designed to provide in-home and community-based services to Medicaid eligible intellectually disabled and developmentally disabled individuals who do not receive Medicaid benefits under a cash assistance program.

To be eligible under the NOW/COMP COA, an A/R must meet the following conditions:

The A/R is assessed for waivered services by an DBHDD Regional Office.

The A/R is approved by the DCH Medical Management contractor, Alliant Healthcare Solutions, evidenced by a completed DMA-7.

The DMA-7 (only used for NOW/COMP) may be approved by the DBHDD Regional Office.

The A/R is placed in a NOW/COMP slot and is receiving NOW/COMP waivered services.

The A/R meets the Length of Stay (LOS) and Level of Care (LOC) basic eligibility criteria.

The A/R meets all other basic and financial eligibility criteria.

NOW/COMP Medicaid recipients receive certain waivered services.

The individual determined suitable through a level of care determination for NOW/COMP is placed under support coordination (case management).

The Support Coordinator arranges for the provision of waivered services to the recipient.

The beginning date of Support Coordination (case management) is the same as the enrollment date for an A/R leaving an institution, and the same as the date services begin for an A/R already residing in the community.

A/Rs who are coming out of an institution may receive Support Coordination for up to six months prior to placement in NOW/COMP and while they are still living in the facility.

Follow the steps below to determine ABD Medicaid eligibility under the NOW/COMP COA.

Step 1 Accept the A/R’s application, the Form 1008, NOW/COMP Communicator, and approved LOC instrument After April 1, 2003, DMA-6s will no longer be completed by GMCF/Alliant but by private vendors contracting with Mental Health. Instead of an actual DMA-6, it will be a mailer containing pertinent information. A new LOC instrument is required upon entry into NOW/COMP Step 2 If the A/Rs income includes SSI, STOP, deny application. SSI NOW/COMP A/Rs' claims are directly billed to DCH through the NOW/COMP agency. Step 3 If the A/R is institutionalized or resides in the community, and is ABD Medicaid eligible, schedule a review when information is received from the Support Coordinator or provider. Proceed to Step 6. Step 4 If the A/R is institutionalized or resides in the community, and is not currently eligible for Medicaid, schedule an initial interview when information is received from the Support Coordinator or provider. Step 5 Determine basic eligibility. Refer to Chapter 2200, Basic Eligibility Criteria. Step 6 Determine financial eligibility. Refer to 2500 ABD Financial Responsibility and Budgeting Overview . Complete a Medicaid Cap Budget to determine income eligibility. Refer to 2510 Medicaid Cap Budgeting . Step 7 Determine if the Length of Stay criteria is met. Refer to 2235 Length of Stay for ABD Medicaid . Step 8 The system will determine the A/R’s Cost Share for NOW/COMP services. Refer to 2559 Patient Liability / Cost Share Budgeting e. The PNA is the same amount as the Medicaid Cap. Step 9 Approve if the A/R meets all eligibility criteria. Do not approve Medicaid under the NOW/COMP COA for any month prior to the month of either the NOW/COMP Enrollment Date or Date Services Begin listed on Form 1008, NOW/COMP Communicator, or prior to 2/1/94, the effective date of the NOW, or 10/1/97, the effective date of the COMP amendment. Step 10 Complete Section III of Form 1008, NOW/COMP Communicator. Enter the Medicaid number at the top of the form. Send to the originating I & E Team with a copy to the Regional Office (as noted on Form 1008). A list of Regional Office addresses and the counties they serve is found at the end of Section 2132. The I & E Team will complete the return address for the I & E Team and the Regional Office. File a copy in the case record. The NOW/COMP Communicator is used to provide required information to the NOW/COMP agency. If the NOW/COMP agency is listed as AREP in Gateway to receive the required notices, it is not necessary for the DFCS case worker to also complete and return the NOW/COMP Communicator. Step 11 Notify the A/R and any authorized representative of case disposition.

Effective March 1, 2002, all DMA-7 forms processed by the I & E Teams for continued LOC will be completed on or before the birth date of the recipient. It will be valid until the following birth date, but not for longer than 365 days.

A new LOC instrument will not be required at annual review unless the review month coincides with the recipient’s birth month. Otherwise, a LOC instrument received in the birth month of a recipient is to be treated as a special review.

The NOW/COMP COA requires one specifically designated form, a Form 1008, NOW/COMP Communicator. The Communicator is maintained by DBHDD.

The NOW/COMP Communicator functions much like the Community Care Communicator (CCC). The form is initiated by the I & E Team completing the following sections:

The top section, with all identifying information except the Medicaid number, unless the A/R is already a Medicaid recipient.

Section I

Section II

Section IV

Section V should include the I & E Team’s address.

Contact Information for Division of Mental Health, Developmental Disabilities and Addictive Diseases can be found on the DBHDD website.

Entity Contact Information General Information dbhdd.georgia.gov/ Regional Field Offices dbhdd.georgia.gov/regional-field-offices Regional Hospitals dbhdd.georgia.gov/be-caring Georgia Crisis & Access Line at 1-800-715-4225

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: TEFRA/Katie Beckett Effective Date: July 2026 Chapter: 2100 Policy Number: 2133 Previous MT Number(s): MT 72 Updated or Reviewed in MT: MT 80

Katie Beckett is a class of assistance (COA) available to children 18 years of age and younger.

These individuals are determined to be in need of institutionalized care but have chosen to remain at home because they can be cared for at a lower cost. Katie Beckett allows the deeming of the income and resources of the child’s parents to be waived when determining ABD Medicaid eligibility.

To be eligible under the Katie Beckett COA, an A/R must meet the following conditions:

The A/R’s age does not extend past the month she or he turns age 19.

The A/R is chronically impaired to the extent of being a suitable candidate for institutionalized care (nursing facility, hospital or intermediate care facility for the intellectually disabled).

The A/R is financially ineligible for SSI in a private living arrangement (LA-A, B or C) due to his or her own income, resources or both and income or resources deemed from his or her parent(s).

Effective 7/1/2023 screening for SSI financial eligibility is no longer a requirement. Furthermore, effective 3/12/2025 referrals to apply for SSI financially is no longer a requirement due to termination of Application for Other Benefits requirement.

The A/R meets the Level of Care (LOC) basic eligibility criteria.

The A/R meets all other basic and financial eligibility criteria.

Length of Stay (LOS) is not a requirement for this COA.

In some situations, a child may be eligible for either EDWP, NOW, COMP, or Katie Beckett. The benefits of each COA should be explained to the parent(s), caregiver(s) or other authorized representative (AREP). Also, the availability of EDWP, NOW, COMP services should be considered.

Follow the steps below to determine ABD Medicaid eligibility under the Katie Beckett COA.

Step 1 Accept the A/R’s Medicaid application. Additionally, for new applications, add the parents' income to the case, add parents to the Applicant Group, and list the parents as the Authorized Representatives in Gateway. Step 2 Screen for SSI financial eligibility: Complete an SSI trial budget, deeming the income, resources or both of the child’s parent(s). Refer to Section 2508 - Parent to Child Deeming . Allow a one-third deduction to the child’s own income if it is Child Support from a non-custodial parent. If the child is financially eligible for SSI, refer the child to SSA for an SSI determination and proceed with the Katie Beckett application. If the child is financially ineligible for SSI, proceed with the Katie Beckett application. Review any reduction in the income or resources that might make the child eligible for SSI. Schedule interim reviews if changes are anticipated and terminate Katie Beckett Medicaid if the child becomes eligible for SSI. Step 3 Give the family or caregiver (or foster care worker if A/R is foster child) a packet of information regarding Katie Beckett COA. Go over forms/instructions with them so that they thoroughly understand how to complete. This packet should include: Form DMA 6A - Physician’s Recommendation for Pediatric Care and instructions for completion Form DMA 706 - TEFRA/Katie Beckett Medical Necessity/Level of Care Statement Form DMA 704 - TEFRA/Katie Beckett Cost-Effectiveness Form The A/R’s family or caregiver (or foster care worker), the attending physician and caseworker have roles in completing a Form DMA 6A - Physician’s Recommendation for Pediatric Care on the A/R. The A/R’s physician and primary caregiver completes the Form DMA 706 - TEFRA/Katie Beckett Medical Necessity/Level of Care Statement that outlines how the child’s needs are met and the desired outcomes. The caregiver (parent or guardian) must sign and date. Foster Care members must have the signature of the DFCS representative. The A/R’s physician completes the Form DMA 704 - TEFRA/Katie Beckett Cost-Effectiveness Form . Step 4 When the family or caregiver (foster care worker) returns the Form DMA 6A - Physician’s Recommendation for Pediatric Care, Form DMA 704 - TEFRA/Katie Beckett Cost-Effectiveness Form and the Form DMA 706 - TEFRA/Kaite Beckett Medical Necessity/Level of Care Statement check the forms to make sure that EVERY question has been addressed, even if completed with N/A (not applicable). The forms must be signed with original signatures by the physician, parent(s) or caregiver(s), and foster care worker as indicated. Stamped signatures are not acceptable. The doctor’s signature date on the Form DMA 6A - Physician’s Recommendation for Pediatric Care is valid for 90 days. Return to the family or caregiver for completion if lacking any of the requirements. Give them a reasonable time frame in which to return information. Step 5 Have the family or caregiver (foster care worker) obtain a signed psychological (6-19 years) or developmental (0 to 5 years) evaluation if any of the following is indicated on the Form DMA 6A - Physician’s Recommendation for Pediatric Care: Section B, item number 13, has a diagnosis of either mental illness, intellectually disabled, autism, or Asperger’s syndrome OR Section C, item number 33, Behavioral Status has ANY of the boxes checked OTHER THAN “Cooperative”, “Alert” or both. The psychological evaluation must be completed by a licensed professional and is required every three (3) years. Licensed professionals approved to do this testing include Developmental Pediatricians and Ph.D. Psychologists. Psychological evaluations completed by school psychologists, preschool diagnosticians, and education diagnosticians with M.Ed., Ed.S., M.A., M.S., CAS, CAGS, Psy.S, Psy.D, SSP, or Ed.D degrees are also accepted. Developmental Evaluations done by Early Interventionist with Babies Can’t Wait are accepted for children with an Individualized Family Service Plan (IFSP). The evaluation must be completed within the last 3 years of the evaluation date whether it is an initial application or review. Give the family or caregiver a reasonable time in which to return the psychological evaluation. Step 6 When the Form DMA 706 - TEFRA/Katie Beckett Medical Necessity/Level of Care Statement is received from the family or caregiver (foster care worker), make sure copies of therapy notes are attached if indicated. The signature date on the Form DMA 706 - TEFRA/Katie Beckett Medical Necessity/Level of Care Statement is valid for 90 days. Step 7 When the Form DMA 706 - TEFRA/Katie Beckett Medical Necessity/Level of Care Statement is received from the family or caregiver (foster care worker), make sure copies of Individualized Family Service Plan (IFSP) or Individualized Education Plan (IEP) are attached if indicated. Step 8 Once the caseworker has received all the necessary information or forms, the caseworker becomes the “gatekeeper” of the material. As such, copies should be made of any data sent to Alliant Health Solutions (AHS). Step 9 The LOC determination is obtained by submitting the following completed items to AHS. Form DMA 6A - Physician’s Recommendation for Pediatric Care Form DMA 705 - TEFRA/Katie Beckett LOC Determination Routing Form Form DMA 706 - TEFRA/Katie Beckett Medical Necessity/Level of Care Statement Psychological (if indicated) Therapy Notes (if indicated) Skilled Nursing Notes (if indicated) IFSP (if indicated) IEP (if indicated) Send ALL items together at one time. Please check all forms and make sure they are complete. Submit packet to: Alliant Health Solutions Attention: TEFRA/Katie Beckett P.O. Box 105406 Atlanta, GA 30348 If at any time the mailing address of the parents of a KB child changes during the LOC determination process please notify AHS via the Form DMA 705 - TEFRA/Katie Beckett LOC Determination Routing Form . Step 10 AHS reviews the information submitted and does the following: If packet is incomplete , AHS will issue an initial denial letter which includes what items are missing. The letter is sent to Katie Beckett Specialized Team and family or caregiver. The family or caregiver will have 30 days to return the missing information to AHS. The address for the family or caregiver to submit information to is printed on the letter. If the family or caregiver mistakenly sends the information to DFCS, forward immediately to AHS to the address on the letter. If additional information is not received by the 30th day then the initial denial letter will become final. If packet is complete , AHS makes the LOC determination. If LOC approval letter is received from AHS, continue with eligibility determination process, Step 15. If LOC is initially denied by AHS, the family or caregiver and DFCS will receive an “Initial Denial of Admission” letter. Proceed to Step 11. Step 11 If AHS denies LOC or family or caregiver fails to appeal, provide additional clinical information or both within the 30 days after the LOC denial, “the initial denial becomes a final denial. If AHS denies LOC after reviewing additional information”, the caseworker and household will receive a Final Determination Denial of Admission. The family or caregiver will have an additional 30 days in which to appeal (remove, provide medical information or both) as currently outlined in the section. When counting days, day one is the first day following the date on the letter, regardless of whether that day is a weekend or a holiday. However, if the 30th day falls on a weekend or a holiday, the next full business day is the 30th day. The address for the family or caregiver to respond to is printed on the letter. If the family or caregiver mistakenly sends the information to DFCS, forward immediately to AHS to the address on the letter. AHS will make a LOC determination and a disability determination, and the caseworker will proceed as follows: If approved, continue with eligibility determination process, Step 15. For applications, the caseworker will deny the case for no LOC. DO NOT SUPPRESS notice. For renewals, see Renewals below. If the family or caregiver challenges the LOC denial, the family or caregiver will send the appeal directly to DCH’s Legal Services at: Georgia Department of Community Health Legal Services Section 2 Martin Luther King Jr. Drive SE East Tower Atlanta, Georgia 30334 The appeal to DCH must be made within 30 days of the date of the LOC denial letter. When counting days, day one is the first day after the date on the letter, regardless of whether that day is a weekend or holiday. However, if the 30 th falls on a weekend or holiday, the next full business day is the 30 th day. Should the family or caregiver send the appeal to DFCS, forward the appeal to DCH’s Legal Services. The state office Medicaid Unit will notify the county if an appeal has been filed. There are no benefits to continue with a denied application. An Administrative Law Judge (ALJ) conducts the hearings for both LOC hearings and hearings for other reasons. However, requests for LOC hearings are routed through DCH Legal Services, not through OSAH. Follow the OSAH procedures ( Appendix B – Hearings TOC) for any hearing requests other than LOC. Step 12 The caseworker will do the following based on the outcome of the final LOC hearing: If the ALJ upholds the LOC denial, the case remains closed. No further action is required. However, if the family or caregiver wants to appeal the ALJ decision, see Step 13. If the ALJ overturns the LOC denial and provides a letter to that effect, the caseworker will register the Katie Beckett case again using the original application date and complete the eligibility determination process. It is not necessary to have the family or caregiver sign a new application. Proceed to Step 15 or any other step not completed. Step 13 To appeal the ALJ decision, the family or caregiver should file a written request for an agency review within 30 days of receipt of the decision to: Department of Community Health Commissioner Dr. Dean Burke Office of the General Counsel 2 Martin Luther King Jr. Drive SE East Tower Atlanta, Georgia 30334 A copy must also be sent to DCH Legal at the same address in Step 11, or they may fax a copy to 404-657-9711. Step 14 Determine the child’s suitability for care under a home care plan in lieu of institutionalized placement using the Form DMA 704 - TEFRA/Katie Beckett Cost-Effectiveness Form and the Form DMA 708 - TEFRA/Katie Beckett Worksheet . Complete a Form DMA 708 - TEFRA/Katie Beckett Worksheet as follows: Based on the approved LOC as determined by AHS, select the Medicaid cost of the appropriate institution using DCH’s provided amounts. Refer to Appendix A1 - ABD Financial Limits TOC for amounts. Base the type of institution chosen by the LOC reflected on the LOC approval letter. Subtract the physician’s estimated monthly cost of home care on the Form DMA 704 - TEFRA/Katie Beckett Cost-Effectiveness Form from the monthly Medicaid billing rate of the institution. If in-home care is more costly, deny the Katie Beckett application. If in-home care is less costly or equal to, proceed with the Katie Beckett application. Take into consideration in the cost comparison process any health or LTC insurance coverage. Do not use GAPP services or costs in the cost-effectiveness determination. This includes skilled nursing care. The caseworker should never complete the Form DMA 704 - TEFRA/Katie Beckett Cost-Effectiveness Form for the family or caregiver. If the doctor leaves any of the form blank, it is up to the family or caregiver to have it completed. Other medical entities may complete and initial the parts of the form that pertain to services they render to the A/R. Step 15 Proceed with the eligibility determination process, completing financial and other Basic Eligibility Criteria, if not already completed. Medicaid eligibility under the Katie Beckett COA is not held to the pay date shown on the LOC approval letter for new applications or LOC expirations. For new applications, the three months prior may be approved even if those months pre-date the pay date on the LOC letter. For LOC expirations, the LOC is approved from the end date of the previous LOC approval even if those dates pre-date the pay date on the LOC approval letter. The end date of the LOC is one year from the date that the LOC determination was completed by AHS, unless the LOC letter indicates otherwise. Step 16 If the A/R meets all eligibility criteria, approve Medicaid in Gateway by entering all pertinent data including any retroactive months. The system will determine financial eligibility using the Medicaid Cap and issue notification letter(s). There is no patient liability for this COA.

Complete a review of eligibility annually and document any anticipated change in resources, income or potential SSI eligibility.

At renewal if not already present in case, add the parent to the applicant group, list the parents as authorize representatives, and add their income to the case.

See Procedures to complete Steps 3, 4 – 9, and 14 - 16. If the Form DMA 6A - Physician’s Recommendation for Pediatric Care indicates that a psychological evaluation is required, see Step 5 for procedures. A psychological is only valid for 3 years from the date of the evaluation. If the Care Plan indicates the A/R receives therapy, follow procedures in Step 6. If the Care Plan indicates IFSP, IEP or both, follow procedures in Step 7.

Children Currently Eligible for Katie Beckett but Do Not Have a Disability Determination:

When a Katie Beckett COA is due for eligibility renewal with an approved LOC but no disability decision, request an updated letter from AHS to include disability.

Complete the following if the LOC is denied :

If the family or caregiver receives a letter of “Initial Denial of Admission” and submits additional clinical information timely to AHS, leave case open pending “Final Determination Denial of Admission” or LOC approval.

If the family or caregiver receives the “Final Determination Denial of Admission” from AHS, the family or caregiver has 30 days to appeal. The MES should close the case effective the end of the month in which the 30-day appeal time falls. DO NOT waive notice.

The Katie Beckett Unit will notify DCH if the family or caregiver has requested an appeal of the LOC. If the family or caregiver appeals and requests that the case remains open pending the appeal or provides additional medical information to AHS, the caregiver should reinstate the case. Add the following text to the reinstatement notice: “Case is reopened pending the outcome of the appeal or reconsideration based on additional medical information.”

If the family or caregiver appeals the denial and the LOC denial is overturned, reinstate the case, if not already reinstated.

If the family or caregiver appeals the denial and the hearing upholds the LOC denial, close the case, if reinstated, and waive the notice. If the family or caregiver wishes to appeal the upheld LOC denial, they should make this appeal in writing to the DCH Commissioner. See Step 13.

If the family or caregiver does not appeal, the case remains closed The end date of the LOC is two years from the date that the LOC determination was completed by AHS, unless the LOC letter indicates otherwise. Never allow the LOC to expire before a new one is obtained. Best practice is to send the Katie Beckett packet with the Form DMA 6A - Physician’s Recommendation for Pediatric Care to the family or caregiver at least a month prior to the expiration of the LOC.

Anytime the A/R becomes ineligible for Katie Beckett Medicaid, terminate the COA and complete a CMD considering all Medicaid COA’s (Waivers, etc.). Refer to Section 2052 - Continuing Medicaid Determination .

In the month after the A/R turns 18 years of age, A/R must be advised to apply for SSI.

Notification will be sent to the A/R, family, caregiver or AREP advising the household of an additional year of Katie Beckett coverage and the requirement to apply for SSI benefits.

Regardless if the A/R provides proof of application for SSI or not, no action will be taken to change the eligibility; rather, the Katie Beckett COA will remain open through the month the A/R turns 19 years of age at which time ongoing eligibility will be reviewed as a CMD considering all Medicaid COAs (Waivers, etc.) and their eligibility criterion before closing the Katie Beckett COA.

Regardless if SSA approves the A/R for SSI or determines A/R not disabled, allow the Katie Beckett COA to remain open through the month the A/R turns 19 years of age due to Continuous Eligibility and close the month after the A/R turns 19. A CMD must still be completed to consider all Medicaid COAs (Waivers, etc.) before closing the Katie Beckett COA.

When completing a CMD from Katie Beckett to an ABD COA, disability requirement must be met either by SSA determination or via SMEU procecures.

A disabled child may be eligible for a $30 SSI personal needs allowance from SSA if she or he meets the following criteria:

Is disabled

Received SSI benefits (limited to PNA) while in a medical treatment facility

Is ineligible for SSI solely because of deemed income or resources of the parents

Is currently eligible for Medicaid under one of the following COAs: Katie Beckett (Section 2133 - TEFRA/Katie Beckett) EDWP ( Section 2131 - Elderly Disabled Waiver Program ) Services under GAPP ( Section 2933 - Georgia Pediatric Program )

If the child meets the above criteria, refer the parent(s) to SSA to continue the SSI $30 PNA payment and Medicaid. Continue to maintain the child under the COA above unless the child no longer meets the criteria for that program.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Hospice Care Effective Date: November 2023 Chapter: 2100 Policy Number: 2135 Previous MT Number(s): MT 58 Updated or Reviewed in MT: MT-71

Hospice Care is a class of assistance (COA) that provides Medicaid to cover care for terminally ill individuals.

To be eligible under the Hospice Care class of assistance an A/R must meet the following conditions:

The A/R has a medical prognosis of six months or less life expectancy.

The A/R is receiving hospice care services from an approved hospice care provider.

The A/R meets the Length of Stay (LOS) and Level of Care (LOC) basic eligibility criteria.

The A/R meets all other basic and financial eligibility criteria

Hospice care services are provided to the A/R by a Medicaid hospice agency. The A/R may reside at home or in a nursing home.

Hospice care services include but are not limited to the following:

nursing home

medical social services

physician services

counseling services

respite care

home health aide services

DMA only reimburses for medical services provided by the hospice care agency. These recipients receive a Medicaid card that identifies them as hospice care recipients, with a notation to medical service providers that all claims must be submitted through the hospice agency. If the A/R has prescription needs which are not covered through the Hospice provider and are not related to the Hospice diagnosis, the authorizing physician must submit to DCH a statement containing the Hospice diagnosis, what the unrelated drug is and why it is necessary. This statement should be sent for approval to: DCH Pharmacy Services Unit 2 Martin Luther King Jr. Drive SE East Tower, 19 th Floor Atlanta, Georgia 30303

All SSI recipients receiving Institutionalized Hospice must be entered and processed in Gateway. These cases should be consistent with case management for SSI only nursing home cases. See 2578 SSI Recipients .

There is no patient liability or cost share for A/Rs in a home setting. However, for Hospice A/Rs in a NH setting, a PL/CS is determined the same as for NH A/Rs. See 2136 Institutionalized Hospice .

Follow the steps below to determine ABD Medicaid eligibility under the Hospice Care COA.

Step 1 Accept the A/R’s Medicaid application Step 2 Verify the following through receipt of a Hospice Care Communicator (HCC) from the hospice agency: A/R’s medical prognosis (life expectancy) A/R’s (or PR’s) election of hospice services Date hospice care services began Step 3 If the A/Rs income includes SSI and not Institutionalized, STOP, deny application. SSI Hospice At Home A/R’s claims are directly billed to DCH through the Hospice agency. Step 4 Conduct an interview. Step 5 Determine basic eligibility, including Length of Stay (LOS) and Level of Care (LOC). Refer to Chapter 2200, Basic Eligibility Criteria. Step 6 Determine financial eligibility. Refer to Chapter 2500, ABD Financial Responsibility and Budgeting, for procedures on whose resources to consider and the resource limit to use in determining resource eligibility. Complete a Medicaid CAP budget to determine income eligibility. Refer to 2510 Medicaid Cap Budgeting . If A/R has income over the Medicaid Cap, refer to 2407 Qualified Income Trust . Step 7 Approve Medicaid on the system using the Hospice Care COA if the A/R meets all the above eligibility criteria. For an A/R receiving hospice care services in a nursing home, determine Institutionalized Hospice eligibility. See 2136 Institutionalized Hospice . Step 8 Notify the A/R of the case disposition via the system. Notify the hospice provider of the case disposition using the Hospice Care Communicator (HCC) and enter the hospice agency as an Authorized Representative in the system. Step 9 Verify at the following intervals through receipt of an HCC that the hospice care provider has received a signed statement from the A/R electing to continue hospice care services: by the end of the first 90-day period of hospice care by the end of the second 90-day period of hospice care every 60 days thereafter Do not approve Medicaid under the Hospice Care COA for any month in which the A/R will not receive hospice services from an approved hospice agency. If the A/R does not elect to continue hospice services at the intervals specified above, complete a CMD. Refer to the 2052 Continuing Medicaid Determination .

For any month in which an A/R is in Hospice care and another COA such as Hospital or Nursing Home, approve the case on the system under the other COA. Use Hospice COA when the A/R is in Hospice and not eligible under any other COA for a specific month.

A/Rs may receive Hospice services while receiving Medicaid through EDWP/CCSP. It is not necessary to terminate the existing EDWP/CCSP case and switch to Hospice. If A/R was eligible under the Hospice COA, switch to EDWP/CCSP. The Hospice and EDWP/CCSP eligibility may occur simultaneously in MHN.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Institutionalized Hospice Effective Date: February 2020 Chapter: 2100 Policy Number: 2136 Previous MT Number(s): MT 54 Updated or Reviewed in MT: MT-58

Institutionalized Hospice is an ABD Medicaid Class of Assistance (COA) that provides Medicaid to terminally ill individuals who receive hospice care services while residing in a Medicaid participating nursing home.

To be eligible under the Institutionalized Hospice COA, an A/R must meet the following conditions:

The A/R is receiving or elects to receive Hospice Care services while residing in a Medicaid participating nursing home.

The A/R has a medical prognosis of six months or less life expectancy.

The A/R is receiving Hospice Care services from an approved hospice care provider.

The A/R meets the Length of Stay (LOS) and Level of Care (LOC) basic eligibility criteria.

The A/R meets all other basic and financial eligibility criteria required for the Hospice Care COA.

A DMA-59 is not required unless the A/R leaves hospice care and remains in the nursing home under Medicaid.

Hospice care services are provided to the A/R by a DMA certified hospice agency. Effective April 1, 2003, Medicaid eligible persons who receive or elect hospice care services while residing in a nursing home must pay a monthly patient liability amount to the hospice care provider. The hospice care provider will pay to the nursing home the patient liability amount.

DMA reimburses only those medical services provided by the hospice care agency. These recipients receive a Medicaid card that identifies them as Hospice recipients, with a notice to medical service providers that all claims must be submitted through the hospice agency.

Follow the steps below to determine ABD Medicaid eligibility under the Institutionalized Hospice COA.

Step 1 Accept the A/R’s Medicaid application Step 2 Verify the following through receipt of a Hospice Care Communicator (HCC) from the hospice agency: A/R’s medical prognosis (life expectancy) A/R’s (or PR’s) election of hospice services The date hospice services began Step 3 Conduct an interview. Step 4 Determine basic eligibility, including Length of Stay (LOS) and Level of Care (LOC). Refer to Chapter 2200, Basic Eligibility Criteria. Step 5 Determine financial eligibility. Refer to Chapter 2500, ABD Financial Responsibility and Budgeting, for determining whose resources to consider and the resource limit to use. Step 6 If the A/R meets all the above eligibility criteria, approve Medicaid on the system. Step 7 Notify the A/R of the case disposition via the system. Notify the hospice provider of the case disposition and Patient Liability using the Hospice Care Communicator (HCC) and enter the hospice provider as an Authorized Representative in the system. Step 8 Verify at the following intervals through receipt of an HCC that the hospice care provider has received a signed statement from the A/R electing to continue Institutionalized Hospice services: by the end of the first 90-day period of Institutionalized Hospice by the end of the second 90-day period of Institutionalized Hospice every 60 days thereafter

Do not approve Medicaid under the Institutionalized Hospice COA for any month in which the A/R will not receive hospice services from an approved hospice agency. If the A/R does not elect to continue hospice services at the intervals specified above, complete a CMD. Refer to Section 2052, Continuing Medicaid Determination.

Effective September 1, 2004, the AMN IH COA will be eliminated due to a change in the State Plan. Complete a CMD to determine if the A/R is eligible under another COA such as regular AMN.

If the A/R was Medicaid eligible under the NH COA prior to IH or no longer elects IH but remains in the NH, enter the appropriate information on the ABD screen(s) in the current eligibility system.

All SSI only recipients receiving Institutionalized Hospice must be entered and processed in Gateway. These cases should be consistent with case management for SSI only nursing home cases. See SSI Recipients, Section 2578.

If the NH is under a Medicaid sanction resulting in a "ban on admissions", no Hospice Care Communicator (HCC) should be sent to DFCS until such time as the ban is lifted. Until the "ban on admissions" is lifted, no A/R should be approved for the IH COA if the A/R is admitted to IH on or after the effective date of the ban on admissions. A ban on admissions has no effect on A/Rs who are already Medicaid recipients in IH or who were admitted to IH prior to the imposition of the ban.

If an application is received on an A/R who was admitted during the time the "ban on admissions" is in place, hold the case until either the ban is lifted and the case can be approved under the IH COA or the standard of promptness (SOP) is reached. If the case cannot be approved under the IH COA by the SOP date, determine eligibility under another COA such as regular AMN. Do not determine eligibility under any LA-D COA. If the "ban on admissions" is subsequently lifted, historically close the other Medicaid case and approve under the IH COA back to the first month of eligibility.

The county DFCS will be copied on the facilities notification of "Denial of Payment" from DCH/Aging and Community Health Services. The county DFCS will also be copied when the Denial of Payment ban is lifted.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Hospital Effective Date: February 2020 Chapter: 2100 Policy Number: 2137 Previous MT Number(s): MT 10 Updated or Reviewed in MT: MT-58

The Hospital Class of Assistance (COA) provides Medicaid for individuals who are hospitalized for at least 30 consecutive days. The period of confinement may include a combination of days in either a Medicaid participating or non-Medicaid participating institution.

To be eligible under Hospital COA, the A/R must meet the following conditions:

The A/R requests Medicaid due to a stay in a Medicaid participating hospital.

The A/R meets the Length of Stay (LOS) and Level of Care (LOC) basic eligibility criteria.

The A/R meets all other basic and financial eligibility criteria.

Follow the steps below to determine ABD Medicaid eligibility under the Hospital COA.

Step 1 Accept the A/R’s Medicaid application. Step 2 Obtain information required to complete the eligibility determination. Step 3 Determine basic eligibility, including Length of Stay (LOS) and Level of Care (LOC). Refer to Chapter 2200, Basic Eligibility Criteria. Step 4 Determine financial eligibility. Refer to Chapter 2500, ABD Financial Responsibility and Budgeting for procedures on whose resources to consider and the resource limit to use in determining resource eligibility. Complete a Medicaid CAP budget to determine income eligibility. Refer to Section 2510 Medicaid Cap Budgeting . There is no patient liability or cost share under this COA. Step 5 Approve Medicaid under the Hospital COA if the A/R meets all the above eligibility criteria. Do not approve Medicaid under the Hospital COA for any month in which the A/R was not hospitalized for at least one day of the month.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Independent Care Waiver Program Effective Date: July 2024 Chapter: 2100 Policy Number: 2139 Previous MT Number(s): MT 64 Updated or Reviewed in MT: MT-72

The Independent Care Waiver Program (ICWP) is a class of assistance (COA) that provides in home care to individuals who are Severely Physically Disabled (SPD) or who have Traumatic Brain Injuries (TBI). SPD individuals are those who cannot physically care for themselves and require assistance from another for daily functioning. These individuals need more care than can be provided by EDWP. ICWP A/Rs must meet the criteria for nursing home placement although they remain at home.

To be eligible under this COA, an A/R must meet the following conditions:

The A/R is between 21 through 64 years of age. Applicants approved prior to age 65 may continue to be eligible after attaining age 65 if they continue to meet all other eligibility criteria.

The A/R is receiving case management services through a DMA approved ICWP case management provider.

The A/R is residing in a residential home situation, such as his/her own home.

The A/R meets the length of stay (LOS) and the level of care (LOC) basic eligibility criteria.

The A/R meets all other basic and financial eligibility criteria.

ICWP Medicaid recipients receive certain waivered services not normally covered by Medicaid, including the following:

case management

companion services

counseling

emergency response system (ERS)

environmental modification

homemaker services

occupational therapy

personal care services

skilled nursing

specialized medical equipment and supplies

transportation

Refer any individuals interested in receiving services under ICWP to:

Alliant Health Solutions P.O. Box 105406 Atlanta, Georgia 30348

(678) 527-3632, (678) 527-3619 or 1-800-982-0411 Local Fax Line: 678-527-3001 Toll Free Fax Line: 1-800-716-5358

The case management provider (case manager) submits the LOC information to Alliant Health Solutions (AHS) and initiates the ICWP services approval process.

The case manager obtains the LOC instrument and sends to DFCS. Receipt of the LOC instrument verifies the LOC for ICWP. A DMA-6 is still a valid LOC instrument for some of the older cases.

The case manager submits an Individual Plan of Care and a Recipient Application form to the DMA Waivered Services Unit for approval of ICWP services. The Waivered Services Unit notifies the case manager of approval or denial of the A/R for ICWP services.

If DMA approves the A/R, the case manager submits an Independent Care Waiver Communicator to DFCS, specifying the date case management began, which is used for LOS, and the date of the first waivered service, which serves as the slot date for eligibility purposes in the same manner as it is used under EDWP.

The beginning date of case management and the slot date should be the same in most cases since case management is a waivered service under ICWP.

If ICWP services are approved by DMA, the case manager and the A/R decide on service providers.

The A/R may apply for ICWP Medicaid while residing at home, in a hospital or in a nursing home.

Follow the steps below to determine ABD Medicaid eligibility under the ICWP class of assistance.

Step 1 Accept the A/R’s ABD Medicaid application. Step 2 Obtain information necessary to process application. Step 3 Verify that the A/R is receiving ICWP services through receipt of an ICWP Communicator from the case manager. The ICWP Communicator should indicate the beginning date of case management and the slot date. Step 4 Determine basic eligibility, including Length of Stay (LOS) and Level of Care (LOC). Refer to Chapter 2200, Basic Eligibility Criteria. Step 5 Determine financial eligibility. Consider the A/R to be in LA-D. See Chapter 2500, ABD Financial Responsibility and Budgeting, for procedures on whose resources to consider and the resource limit used in determining resource eligibility. Complete a Medicaid Cap budget to determine income eligibility. See Medicaid CAP Budgeting in Chapter 2510. If client’s income exceeds the Medicaid CAP, then client must establish a QIT in order to be determined eligible. If the A/Rs income includes SSI, STOP, deny application. SSI ICWP claims are directly billed to DCH through ICWP. Step 6 Determine the A/R’s cost share using the Community Spouse Maintenance Need Standard (CSMNS) as the personal needs allowance (PNA) and all other policies applicable to patient liability/cost share budgeting. If AR is over the Medicaid CAP and has a QIT please remember that there is the potential of a cost share with these cases. Step 7 Notify the A/R of eligibility/cost share. Do not approve Medicaid under the ICWP class of assistance for any month prior to the month of the slot date. Do not approve Medicaid under the ICWP COA if the A/R is under age 21 or age 65 or older. Step 8 Notify the ICWP Case manager by: Entering the Case Manager’s name and address in the system as an Authorized Representative. The Case Manager will then receive information concerning dates of eligibility and cost share. OR Completing Section II of the ICWP Communicator. Enter the Medicaid number on the top of the form. Send one copy to the Case Manager and scan the other into the document imaging system.

The ICWP class of assistance requires the Independent Care Waiver Communicator (ICWC) form as a means for the ICWP Case Manager to communicate with the DFCS Eligibility Worker. The Eligibility Worker may use this form or the system as a means of relaying ICWP approval, denial, or termination information to the Case Manager. Make copies of this form, found at the end of this section, as needed.

The ICWC functions much like the Community Care Communicator (CCC). The form is initiated by the case manager and forwarded to DFCS after the A/R is approved for ICWP services. The case manager completes the following sections of the ICWC:

The top section, with all identifying information except the Medicaid number unless the A/R is already a Medicaid recipient.

Section I, giving the date case management began, the slot date, and a request for a determination of Medicaid eligibility (if needed) and cost share amount.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Nursing Home Effective Date: February 2020 Chapter: 2100 Policy Number: 2141 Previous MT Number(s): MT 49 Updated or Reviewed in MT: MT-58

Nursing Home is a class of assistance (COA) that provides Medicaid to individuals residing in a Medicaid participating nursing home.

To be eligible under nursing home COA, an A/R must meet the following conditions:

The A/R is in a Medicaid participating nursing home, swing bed, facility for mentally retarded or Tertiary Care Unit (TCU) (See Section 2581 for Swing Bed.)

The A/R meets the Length of Stay (LOS) and Level of Care (LOC) basic eligibility criteria.

The A/R meets all other basic and financial eligibility criteria.

Please see Section 2143 regarding Medicare Skilled Nursing Facility (SNF) for QMB

Follow the steps below to determine ABD Medicaid eligibility under the Nursing Home COA.

Step 1 Accept the A/R’s Medicaid application. Step 2 Verify from the receipt of a Form DMA-59 from the nursing home that the A/R resides in a nursing home or TCU. Verify from the receipt of an approved LOC instrument that the A/R resides in a swing bed or that the A/R is in a facility for the mentally retarded (may be a NH). Step 3 Conduct an interview. A telephone interview is acceptable. Step 4 Determine basic eligibility, including Length of Stay (LOS) and Level of Care (LOC). LOC verification may vary depending on whether A/R is in NH, TCU, swing bed or has a LOC of IC-MR. Refer to Chapter 2200, Basic Eligibility Criteria. Step 5 Determine financial eligibility. Refer to Chapter 2500, ABD Financial Responsibility and Budgeting for procedures on whose resources to consider and the resource limit to use in determining resource eligibility. Complete a Medicaid CAP budget to determine income eligibility. Refer to Section 2510, Medicaid CAP Budgeting Step 6 Approve Medicaid using the Nursing home COA if the A/R meets all the above eligibility criteria. The system will determine the A/R’s patient liability based on information entered. Do not approve Medicaid under the Nursing Home COA for any month in which the A/R was not confined to a nursing home for at least one day of the month. Step 7 Notify the A/R and/or PR and the nursing home of the case disposition and patient liability.

Effective September 1, 2004, AMN-NH will be eliminated due to a change in the State Plan. Complete a CMD to another COA, such as AMN (Section 2150).

If the NH is under a Medicaid sanction resulting in a “ban on admissions”, no DMA-59 should be sent to DFCS until such time as the ban is lifted. Until the “ban on admissions” is lifted, no A/R should be approved for the NH COA if the A/R is admitted to the NH on or after the effective date of the ban on admissions. A ban on admissions has no effect on A/Rs who are already Medicaid recipients in the NH or who were admitted to the NH prior to the imposition of the ban.

If an application is received on an A/R who was admitted during the time the “ban on admissions” is in place, hold the case until either the ban is lifted and the case can be approved under the NH COA or the standard of promptness (SOP) is reached. If the case cannot be approved under the NH COA by the SOP date, determine eligibility under another COA such as regular AMN. Do not determine eligibility under any LA-D COA. If the “ban on admissions” is subsequently lifted, historically close the other Medicaid case and approve under the NH COA back to the first month of eligibility.

The “Denial of Payment” notification letters will come to the Medicaid Policy Unit from DCH’s Member Services. The Medicaid Policy Unit will forward the letters to the appropriate Field Program Specialist who will then forward to the county DFCS office. When the Denial of Payment ban is lifted this same process will take place.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Qualified Medicare Beneficiaries Effective Date: June 2025 Chapter: 2100 Policy Number: 2143 Previous MT Number(s): MT 71 Updated or Reviewed in MT: MT 74

Qualified Medicare Beneficiaries (QMB) is a Q-Track class of assistance (COA) that provides a Medicare supplement to individuals who meet financial criteria based on the Federal Poverty Level (FPL).

To be eligible under this COA an A/R must meet the following conditions:

The A/R is enrolled in Medicare Part A, Parts A and Part B, or Part B only.

The A/R meets all basic eligibility criteria. Applicants/Recipients who are entitled to or enrolled in Medicare are exempt from the citizenship verification requirement. Citizenship was verified by SSA prior to awarding Medicare. A Declaration of U.S. Citizenship is still required. Individuals who attest to satisfactory immigration status must have their immigration status verified through SAVE as there are some differences in the immigrant eligibility between Medicare and Medicaid. Length of Stay (LOS) and Level of Care (LOC) are not requirements under this COA.

The A/R has countable resources of less than or equal to the current QMB/SLMB/QI-1 resource limit.

The A/R has countable net income of less than or equal to the QMB income limit.

QMB pays the following for the QMB eligible individual:

the monthly premium for Part A Medicare for those individuals who must pay a premium

the monthly premium for Part B Medicare

all Medicare co-insurance payments (the 20% of covered charges that Medicare will not pay)

all Medicare deductibles, such as the in-patient hospital deductible

Effective for dates of service on or after May 11, 2012, payments for Medicare coinsurance, copayments, and deductibles for dual Medicare/Medicaid members, including QMB, will be limited to the Medicaid maximum allowable amount. If the Medicare payment on a claim is equal to or greater than the Medicaid maximum allowable amount, Medicaid will not pay anything on the claim. All Medicare providers are prohibited from billing QMB recipients for Medicare cost-sharing. This includes Medicare coinsurance, copayments, and deductibles. (See Special Considerations at the end of this section.)

QMB will not cover any medical service that is not covered by Medicare.

Applicants for QMB must meet all eligibility criteria for this COA in the month of approval and the following month in order to be approved.

There is no retroactive coverage under this COA. QMB eligibility begins the first day of the month following the month the eligibility determination is completed.

If the individual is enrolled in Part B, but not Part A, determine them eligible for QMB if they otherwise meet the eligibility criteria.

If an individual is age 65 or older and neither enrolled in Part A nor Part B, direct the individual to file a conditional Part A application at SSA for the purposes of applying for QMB. Individuals can conditionally enroll in Part A at SSA at any time of the year, without regard to Medicare enrollment periods.

The conditional enrollment process allows an individual to apply for premium Part A at SSA on the condition that they will only be enrolled in Part A if the individual then applies for Medicaid at DFCS and is determined eligible for QMB. If DFCS determines the individual ineligible for QMB, SSA will not establish Part A entitlement.

As part of the conditional Part A application, SSA will enroll an individual in Part B.

SSA will process applications for Part B Medicare without regard to QMB eligibility.

An individual who has income less than the FBR may be eligible for QMB and not eligible for SSI because of excess resources.

In-kind Support and Maintenance (ISM) is not considered in determining QMB eligibility.

The QMB income limit is based on the FPL. The FPL/QMB income limit is subject to change between February and April of each year. Therefore, the annual January RSDI COLAs are disregarded in determining QMB eligibility until the effective month of the new QMB income limit.

Refer to Special Considerations in this section for procedures on processing the QMB application for SSI individuals.

THE STANDARD OF PROMPTNESS FOR QMB APPLICATIONS IS 10 WORKING DAYS FROM RECEIPT OF THE APPLICATION.

The 1999 Government Performance Results Act simplified the policy and procedures for this class of assistance and has changed the application process. In addition to applying at the county office, an A/R may apply with the local Community Health Center or with Georgia SHIP (formerly known as GeorgiaCares) on a simplified application on Form 700 -Application for Medicaid & Medicare Savings for Qualified Beneficiaries . (County DFCS shall also use this application form which is available from Central Supply.)

Any applications that are sent to DCH will be forwarded to the appropriate County Departments. The application date is the date stamped as received by DCH.

Follow the steps below to determine QMB eligibility .

Step 1 Accept the A/R’s QMB application. A face-to-face contact and office interview is not required at initial application or annual redetermination. Step 2 Contact the A/R by telephone only if information provided on the application is not sufficient to process the case. Step 3 Verify Part A Medicare entitlement by one of the following: client statement, if copy of card or other written verification is not provided or available a RSDI Award Letter a Medicare card BENDEX, SOLQ under Interfaces in Gateway an MBR Query Card notification from a local SSA office Step 4 Determine all basic eligibility criteria except LOS and LOC. Accept A/R’s statement regarding residency. Refer to Chapter 2200, Basic Eligibility Criteria. To fulfill the TPL requirement on a QMB applicant who reports a TPL, copy the application and send to the DCH TPL Unit. Attach a copy of the insurance card if available. Step 5 Determine financial eligibility. Refer to Chapter 2500, ABD Financial Responsibility and Budgeting to determine the following: whose income and resources to consider which QMB income and resource limit (individual or couple) to use which eligibility budget to complete For all applications and annual redeterminations: The A/R’s statement of income and resources provided on the application/review form is acceptable verification. No further verification is required unless questionable. Call, if needed, to confirm TPL status. If BENDEX/SDX/SOLQ or other information known to the agency indicates a different amount from the A/R’s statement and is determined to be current, use this amount over the A/R’s statement. If a Medicare eligible couple both apply for a Q-Track COA and they are income ineligible as a couple for all Q-Track COA, calculate their eligibility as individuals for income but jointly for resources and approve each under whichever Q-Track COA they are eligible. No property search is required for this class of assistance. The Social Security number of a spouse who is not applying for benefits is not required unless eligibility cannot be established without it. Step 6 Approve QMB on the system to begin the month following the month of case disposition if the A/R meets all the above eligibility requirements. However, if approval of the case is not completed within the standard of promptness due to agency or other agency delay, use the QMB override feature to not penalize the A/R for any month(s) in which the individual meets all of the eligibility requirements in that month, as long as it is for a month after the month of application. Step 7 Notify the A/R of the case disposition via the system generated notice.

Effective August 1991, SSI Only recipients must apply for and be approved for QMB before DCH will pay the Part A Medicare premium through the buy-in process.

The following SSI recipients must apply for QMB at DFCS in order to have the premium paid by DCH:

Aged SSI Only recipients who are enrolled in Part B only. These individuals are eligible for Part A Medicare with a monthly premium. SSI Only (without RSDI or RR income) recipients who are age 65 or older are eligible for Part A Medicare with a monthly premium. The member will not receive Part A until the QMB application is approved.

SSI recipients (SSI only) whose claim number ends with an “M”. This information can be confirmed by viewing electronic sources such as (SDX, BENDEX and SOLQ).

The following SSI Only recipients will receive a letter from DCH informing them of the need to apply for QMB:

SSI applicants aged 65 or older who are newly approved by SSA to receive SSI

SSI recipients who reach age 65

The SSI Only recipient must submit an application for QMB through DFCS.

In October 2017, DCH issued a memorandum regarding SSI recipients eligible for Part B only (eligible for Medicare premium Part A). DFCS eligibility workers should accept and make an eligibility determination on an MSP application from any SSI-eligible individual , provided the individual is enrolled in Part A, Parts A and B, or Part B only. Although DCH pays the Medicare Part B premium for SSI-related Medicaid members when they become entitled, they must file an application with DFCS for QMB if they have a Medicare claim number that ends with “M" and wish to have the Part A Medicare premium paid by DCH.

Current SSI eligibility is prima facie evidence of financial eligibility for QMB. The SDX record showing current SSI pay status is acceptable verification. Document the case that the SDX screen has been viewed.

DFCS eligibility workers must enroll individuals in Medicare Part A buy-in after the QMB eligibility determination. Workers should not refer individuals to SSA to apply for Part A. Part B enrollment indicates they are eligible for Part A with a monthly premium.

Follow the steps below to establish QMB eligibility for an SSI Only and/or combo recipient.

Step 1 Register the applicant on the system. Step 2 Obtain information necessary to process the application. An interview is not required. Additional information may be obtained by contacting the applicant by telephone or mail. Step 3 Document QMB financial eligibility based on receipt of SSI. An SSI certification letter is acceptable verification if SDX is not available. Step 4 Scan a copy of the letter referring the recipient to DFCS to apply for QMB Into current document imaging system. Step 5 Verify potential Part A Medicare eligibility by one of the following: the DCH letter to the A/R regarding QMB and Buy-In the A/R’s DOB on SDX showing current age as 65 or older “AI” at the end of the SSI claim letter an SSI certification letter SOLQ If none of these methods of certification are available, request the A/R obtain a letter from SSA verifying potential eligibility for Part A Medicare entitlement. Step 6 Approve QMB to begin the month following the month of case disposition if the A/R meets eligibility requirements as an SSI recipient. Step 7 Notify the A/R of the case disposition via the system.

Redetermine eligibility in the month due by means of a telephone contact with the client and review of SDX to show that the client remains in current SSI pay status. Since A/R is SSI eligible, no further forms or contact is required.

If the QMB recipient qualifies for Medicare Skilled Nursing Facility (SNF) care, Medicaid is required to pay the copayments even if that amount is zero. QMB individuals are not required to apply for Nursing Home Medicaid if they do not desire to do so. (Note: after the first 100 days in a benefit period QMB recipients will be responsible for all costs.)

When a QMB recipient is admitted to a nursing facility under Medicare SNF care, the nursing facility will complete a Form DMA-59, Sections I, II, and III and email form to dma-59.forms@dch.ga.gov . The nursing facility will notify DCH when the individual is discharged from Medicare SNF care by completing Section IV of the same Form DMA-59 and emailing the form to dma-59.forms@dch.ga.gov .

If an individual is already eligible for QMB or SLMB and later applies for, and is eligible for, a full Medicaid aid category, such as SSI, Nursing Home or Waivered Services, the MSP program should remain open. The individual is dually eligible.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Specified Low-Income Medicare Beneficiaries Effective Date: June 2025 Chapter: 2100 Policy Number: 2144 Previous MT Number(s): MT 58 Updated or Reviewed in MT: MT-74

Specified Low-Income Medicare Beneficiaries (SLMB) is a Q-Track class of assistance (COA) that pays the monthly premium for Medicare Supplemental Medical Insurance (Part B) for individuals who meet financial criteria based on a percentage of the Federal poverty level (FPL).

To be eligible under this COA, an A/R must meet the following conditions:

The A/R is enrolled in Medicare Part A, Parts A and Part B, or Part B only.

The A/R meets all basic eligibility criteria. Because SLMB recipients receive Medicare, they are exempt from the citizenship verification requirement. Citizenship was verified by SSA prior to awarding Medicare. The Declaration of Citizenship form is still required. Third Party assignment, Length of Stay (LOS) and Level of Care (LOC) are not requirements under this COA.

The A/R has countable resources of less than or equal to the current QMB/SLMB/QI-1 resource limit.

The A/R has countable net income of less than the SLMB income limit but greater than the QMB income limit.

SLMB pays only the monthly premium for Part B Medicare for the SLMB eligible individual.

Retroactive coverage (three months prior) is allowed under this COA. SLMB eligibility cannot pre-date January 1993.

The SLMB income limit is based on the federal Poverty level (FPL). The FPL/SLMB income limit is subject to change between February and April of each year. Therefore, the annual January RSDI COLAs are disregarded in determining SLMB eligibility until the effective month of the new SLMB income limit.

In-kind support and maintenance (ISM) is NOT considered in determining SLMB eligibility.

THE STANDARD OF PROMPTNESS FOR PROCESSING A SLMB APPLICATION IS 10 WORKING DAYS FROM THE DATE OF RECEIPT OF THE APPLICATION.

The 1999 Government Performance Results Act simplified the policy and procedures for this class of assistance and has changed the application process. In addition to applying at the county office, an A/R may apply with the local Community Health Center or with Georgia SHIP (formerly known as GeorgiaCares and HICARE) on a simplified application form, Form 700 - Application for Medicaid and Medicare Savings for Qualified Individuals . (County DFCS shall also use Form 700 for initial applications and annual reviews. It is available from Central Supply.)

The local Community Health Center and Georgia SHIP will forward all applications to DCH, who will forward the applications to the appropriate County Departments. The application date is the date stamped as received by DCH.

Follow the steps below to determine SLMB eligibility.

Step 1 Accept the A/R’s SLMB application. Step 2 Contact the A/R by telephone only if information provided on the application is not sufficient to process the case. A face-to-face contact and office interview is not required at initial application or annual redetermination. Step 3 Verify Part A Medicare entitlement by one of the following: client statement, if copy of card or other written verification is not provided or available a RSDI Award Letter a Medicare card BENDEX, SOLQ under Clearinghouse on the system an MBR Query Card notification from a local SSA office If the A/R has not been approved for Part A Medicare, but is entitled to free Part A, obtain notification from SSA, scan into document imaging system and process SLMB as though the A/R is currently covered by Part A Medicare. (If an A/R is required to pay a premium to receive Part A Medicare, he/she is not considered entitled for purposes of eligibility for SLMB.) Step 4 Determine all basic eligibility criteria except LOS and LOC. Accept the A/R’s statement regarding residency. Refer to Chapter 2200, Basic Eligibility Criteria. To fulfill the TPL requirement on a SLMB applicant who has a TPL, copy the application and send to DCH only if the SLMB applicant becomes Medicaid eligible under another COA. Attach a copy of the insurance card, if available. Step 5 Determine financial eligibility using SLMB income and resource limits. Refer to Chapter 2500 - ABD Financial Responsibility and Budgeting to determine the following: whose income and resources to consider which SLMB income and resource limit (individual or couple) to use which eligibility budget to complete For all applications and annual redeterminations: The A/R’s statement of income and resources provided on the application/review form is acceptable verification . No further verification is required unless questionable. If BENDEX/SDX/SOLQ or other information known to the agency indicates a different amount from the A/R’s statement and is determined to be current, use this amount over the A/R’s statement. If a Medicare eligible couple both apply for a Q-Track COA and they are income ineligible as a couple for all Q-Track COA, calculate their eligibility as individuals for income but jointly for resources and approve each under whichever Q-Track COA they are eligible. No property search is required for this class of assistance. The Social Security number of a spouse who is not applying for benefits is not required unless eligibility cannot be established without it. Step 6 If the A/R meets all the above eligibility requirements, approve SLMB by entering the information in the current eligibility system and approve the case for SLMB. Step 7 Notify the A/R of the case disposition via the system generated notice.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Qualifying Individuals – 1 Effective Date: June 2025 Chapter: 2100 Policy Number: 2145 Previous MT Number(s): MT 58 Updated or Reviewed in MT: MT 74

Qualifying Individuals – 1 (QI-1) is a Q-Track class of assistance (COA) that pays the monthly premium for Medicare supplemental Medical Insurance (Part B) for individuals who meet financial criteria based on a percentage of the Federal Poverty Level (FPL). Eligibility criteria are identical to SLMB except that the coverage is time limited depending on available State funds and the income limit is higher than the SLMB limit.

To be eligible under this COA, an A/R must meet the following conditions:

The A/R is enrolled in Medicare Part A, Parts A and Part B, or Part B only.

The A/R meets all basic eligibility criteria. Since QI-1 recipients receive Medicare, they are exempt from the citizenship verification requirement. Citizenship was verified by SSA prior to awarding Medicare. The Declaration of Citizenship form is still required. Third Party assignment, Length of Stay (LOS) and Level of Care (LOC) are not requirements under this COA.

The A/R has countable resources of less than or equal to the current QMB/SLMB/QI-1 resource limit.

The A/R has countable net income of less than the QI-1 income limit but greater than the SLMB income limit.

QI-1 pays only the monthly premium for Part B Medicare for the QI1 eligible individual.

Retroactive coverage (three months prior) is allowed under this COA. QI-1 eligibility cannot pre-date January 1998.

The QI-1 income limit is based on the federal Poverty level (FPL). The FPL/QI-1 income limit is subject to change between February and April of each year. Therefore, the annual January RSDI COLAs are disregarded in determining QI-1 eligibility until the effective month of the new QI-1 income limit.

In-kind support and maintenance (ISM) is NOT considered in determining QI-1 eligibility.

THE STANDARD OF PROMPTNESS FOR PROCESSING A SLMB APPLICATION IS 10 WORKING DAYS FROM THE DATE OF RECEIPT OF THE APPLICATION.

The 1999 Government Performance Results Act simplified the policy and procedures for this class of assistance and has changed the application process. In addition to applying at the county office, an A/R may apply with the local Community Health Center or with HICARE on a simplified application form, DCH 700, Medicare Savings for Individuals. (County DFCS shall also use Form 700 for initial applications and annual reviews. It is available from Central Supply.)

The local Community Health Center and Georgia SHIP (formerly known as GeorgiaCares and HICARE) will forward all applications to DCH, who will forward the applications to the appropriate County Departments. The application date is the date stamped as received by DCH.

Follow the steps below to determine QI-1 eligibility.

Step 1 Accept the A/R’s QI-1 application. Since this is a time limited program, it is important to take and process applications in chronological order. Step 2 Contact the A/R by telephone only if information provided on the application is not sufficient to process the case. A face-to-face contact and office interview is not required at initial application or annual redetermination. Step 3 Verify Part A Medicare entitlement by one of the following: client statement, if copy of card or other written verification is not provided or available a RSDI Award Letter a Medicare card BENDEX, SOLQ under interfaces in Gateway an MBR Query Card notification from a local SSA office If the A/R has not been approved for Part A Medicare, but is entitled to free Part A obtain notification from SSA, scan into document imaging system and process QI-1 as though the A/R is currently covered by Part A Medicare. (If an A/R is required to pay a premium to receive Part A Medicare, they are not considered entitled for purposes of eligibility for QI-1.) Step 4 Determine all basic eligibility criteria except LOS and LOC. Accept the A/R’s statement regarding residency. Refer to Chapter 2200, Basic Eligibility Criteria. To fulfill the TPL requirement on a QI-1 applicant who has a TPL, copy the application and send to DCH only if the QI-1 applicant becomes Medicaid eligible under another COA. Step 5 Determine financial eligibility using QI-1 income and resource limits. Refer to the Section 2500 - ABD Financial Responsibility and Budgeting Overview to determine the following: whose income and resources to consider which QI-1 income and resource limit (individual or couple) to use which eligibility budget to complete Effective July 1, 2016, DCH adopted SSA’s Low Income Subsidy definition for “family of the size involved” for the QI1 Class of Assistance only . This means we will use the couple income and resource limit for the individual and the individual’s spouse, whether or not the spouse is applying (Medicare Eligible) for the QI1 MSP. We will continue to follow the approach of the SSI program under which either the standard for an individual or the standard for a couple will be used for the QMB and SLMB Medicare Savings Programs. For all applications and annual redeterminations: The A/R’s statement of income and resources provided on the application/review form is acceptable verification . No further verification is required unless questionable. If BENDEX/SDX or other information known to the agency indicates a different amount from the A/R’s statement and is determined to be current, use this amount over the A/R’s statement. If a Medicare eligible couple both apply for a Q-Track COA and they are income ineligible as a couple for all Q-Track COA, calculate their eligibility as individuals for income but jointly for resources and approve each under whichever Q-Track COA they are eligible. No property search is required for this class of assistance. The Social Security number of a spouse who is not applying for benefits is not required unless eligibility cannot be established without it. Except for AMN, an individual cannot be dually eligible for QI-1 and another Medicaid COA for ongoing eligibility. If an active QI-1 A/R applies for and is approved ongoing under another COA, close the QI-1 case. Step 6 Approve QI-1 on the system if the A/R meets all the above eligibility Requirements. Step 7 Notify the A/R of the case disposition via the system generated notice.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Low Income Subsidy (Extra Help for Medicare Part D) Effective Date: February 2020 Chapter: 2100 Policy Number: 2146 Previous MT Number(s): MT 55 Updated or Reviewed in MT: MT-59

Certain Medicare recipients may be eligible to receive a Low-Income Subsidy (LIS) to help pay for the expenses incurred under Medicare Part D.

Anyone may apply for the LIS. However, to be eligible to receive the LIS or Extra Help, an A/R must meet the following conditions:

Be eligible for or enrolled in Medicare Parts A and B AND

Be a recipient for full Medicaid benefits,

OR Q Track,

OR have limited income and resources (Refer to Appendix A1 for current limits.)

If the Medicare recipient is determined eligible for the LIS, s/he will not be reimbursed for any out of pocket Medicare Part D expenses incurred. Once that information is updated in Social Security’s and/or Centers for Medicaid and Medicare Services' system, then the premiums and deductibles should be covered.

DFCS staff may be requested to assist in helping Medicare recipients apply for the LIS. The LIS application (LISA) is completed on a Form SSA -1020B – OCR-SM. Applications may be accepted as early as May 2005. If the Medicare recipient insists on having the State determine the eligibility for the LIS, contact your Medicaid Program Specialist.

Also see Sections 2751 and 2931 for more information.

Follow the steps below in completing the LISA :

Step 1 The LISA MUST be completed on an original Form SSA-1020B. Photocopies should only be made for filing purposes and/or to determine eligibility for Medicaid COAs. Recipients may come with their own LISA application on which some information may be preprinted. If not, provide the recipient with the LISA and complete needed information. Step 2 Refer recipients to GeorgiaCares (1-800-669-8387) for the Prescription Plan explanations and help in enrolling in the Medicare Part D. Refer to Section 2931, Medicare Part D. Step 3 Complete one application for legally married couples living together. For others complete an individual application. Step 4 Complete application using ONLY black ink or # 2 pencil . Any block which must be “checked” should be done using an X . Step 5 Even though there is not a “field” provided, write the date the application was taken in the upper right-hand corner of the LISA in the MMDDYYYY format. This date must be handwritten as a date stamp will void the form. Step 6 In the State code blocks, enter GA. Do not mark “WBDOC Exception” Official Use in Wilkes-Barre Only. Step 7 Print the recipient’s name and SSN in the blocks provided in number 1 of the LISA, beginning with the Last Name. Make sure it matches the Medicare card. Step 8 If recipient is legally married, print the spouse’s name and SSN in the blocks provided in number 2, beginning with the Last Name. Make sure it matches the Medicare card. Be sure to check whether the application is for one spouse or both. Step 9 When completing numbers 3 - 7, remember resource exclusions for FBR COAs, such as $1500 burial exclusion per person, $3000 per couple ($5000/$10,000 non FBR), homeplace, vehicle, etc. Accept the recipient’s statement as to the value of assets. It is not necessary to verify unless this application is also used for a Medicaid COA which requires verification. Step 10 Question number 8 address household size. Make sure, for purposes of the LISA, the recipient understands that s/he will have a higher income limit based as the household size increases. Include any relative (related by blood, marriage or adoption) in the household size for which the recipient provides at least one-half of the financial support. Refer to Appendix A1 for Federal Poverty Level Tables. Step 11 Number 9 refers to unearned income. Do not enter RSDI or SSI income. However, if the application will be used for a Medicaid application, ask and accept the recipient’s statement regarding RSDI/SSI income. Annotate on the copy only. Enter the gross amounts of any other unearned income based on what the recipient tells you. It is not necessary to verify unless this application is also used for a Medicaid COA, which requires verification. Step 12 In number 11, enter the amount the recipient reports as being provided. Step 13 Numbers 12 – 16 refer to earned income. Accept the recipient’s statement as to the amount of earnings. It is not necessary to verify unless this application is also used for a Medicaid COA which requires verification. Step 14 Page 6 is the signature page. Both the recipient and spouse should sign in Section A, if available. If one or both are not available, a representative may sign for them. The MES should sign in Section B. Enter an X in “Other” and “Georgia DFCS” in the space provided. Step 15 Make 2 copies of the form. Give one copy to the recipient or the person acting on their behalf. Use the other to screen for Medicaid and FS eligibility the same day the LISA is completed. If the A/R appears to be potentially eligible for FS provide him/her with a Form 297 to apply for the FS using the current date as the application date. If the recipient appears eligible for a Medicaid COA, follow regular application processing standards. Another Medicaid application form is not required although additional information and verifications may be required. If the A/R is ineligible for ANY Medicaid COA, then register and deny on Georgia Gateway Step 16 If the A/R is Medicaid eligible, do not send the 1020 to SSA. If the A/R is NOT Medicaid eligible, mail the ORIGINAL LISA the same day as completed in the postage paid envelope to: Social Security Administration Wilkes Barre Data Operations Center P.O. Box 1020 Wilkes Barre, Pennsylvania 18767-1020 Additional LISAs may be obtained from your local SSA.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Qualified Disabled Working Individuals Effective Date: February 2020 Chapter: 2100 Policy Number: 2147 Previous MT Number(s): MT 13 Updated or Reviewed in MT: MT-58

Qualified Disabled Working Individuals (QDWI) is a class of assistance (COA) that provides payment of the monthly Part A Medicare premium for disabled working individuals.

To be eligible for QDWI coverage, an A/R must meet the following conditions:

The A/R is under the age of 65.

The A/R is entitled to but not receiving RSDI disability benefits because s/he has earnings that exceed the substantial gainful activity (SGA) limits.

The A/R is eligible for Part A Medicare coverage with a monthly premium.

The A/R meets all basic and financial eligibility criteria. Length of Stay (LOS), Level of Care (LOC) and TPR assignment are not requirements of this COA.

In-kind support and maintenance (ISM) is not considered in determining QDWI eligibility.

The only coverage this COA provides is payment of the monthly Part A Medicare premium by Medicaid. No other medical expenses incurred by the QDWI recipient are paid by Medicaid.

A Medicaid card is not issued to QDWI recipients and Form 962 is not issued to the recipient or providers.

QDWI eligibility cannot begin prior to the A/R’s eligibility for Part A Medicare.

Follow the steps below to determine QDWI eligibility.

Step 1 Accept the A/R’s Medicaid application. Step 2 Obtain information required to complete the eligibility determination. Step 3 Determine that the A/R is ineligible for full Medicaid coverage under all other COAs. Step 4 Obtain the following verification from the Social Security Administration: The termination of the A/R’s RSDI disability payment due to excessive earned income. The A/R’s eligibility for Part A Medicare coverage with a monthly premium. Step 5 Determine all basic eligibility criteria except LOS, LOC and TPR. Refer to Chapter 2200, Basic Eligibility Criteria. Step 6 Determine financial eligibility using the current QDWI income and resource limits. Refer to Chapter 2500, ABD Financial Responsibility and Budgeting to determine the following: whose income and resources to consider which SSI income and resource limit (individual or couple) to use which eligibility budget to complete. Step 7 Approve under QDWI COA if the A/R meets all the above eligibility criteria, including retroactive months if needed.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Georgia Medicaid for Workers with Disabilities Effective Date: May 2026 Chapter: 2100 Policy Number: 2149 Previous MT Number(s): MT 72 Updated or Reviewed in MT: MT 79

Georgia Medicaid for Workers with Disabilities (GMWD) offers people with disabilities, who are working, the opportunity to buy health care coverage through the Georgia Medicaid Program. This Program became effective March 2008.

The “Ticket to Work and Work Incentives Improvement Act of 1999” (TWWIIA) enacted on December 17, 1999, provided states with new options for making it possible for people with disabilities to join, or remain in, the workplace without fear of losing their Medicare and Medicaid coverage. Georgia elected to provide Medicaid coverage in the “Basic Coverage Group” of TWWIIA. Under this group, Medicaid can cover individuals at least 16, but less than 65 years of age, who except for earned income would be eligible to receive SSI.

This program provides Medicaid coverage to workers with disabilities who are employed but are no longer eligible for SSI due to increased earnings. There is no requirement other than an individual must have at one time been a recipient of SSI or SSA disability. However, if an individual was not a recipient of SSI or SSA disability, a disability determination must be completed. Other GMWD non-financial and financial eligibility criteria are based on similar ABD Medicaid Categories.

To qualify for GMWD, an individual must meet all of the following criteria:

Have a disability that meets Social Security Administration’s standards

Have disability income between $600.00-$699.00/month

Be employed and receiving compensation

Be a Georgia resident

Be at least 16 years of age, but less than the age of 65

Have countable income less than the Medicaid Cap (300 percent of the FPL)

Have countable resources less than $4000.00 for an individual, $6000.00 for couple

GMWD participants may be required to pay a monthly premium. Premium amount is based on the individual’s age and total countable income.

Application may be submitted in the following ways:

Online at gateway.ga.gov

Telephonically by calling 1-877-423-4746

Paper application by mail, fax, or in person at the local DFCS office. dfcs.georgia.gov/

Individuals approved for GMWD may be required to pay a monthly premium. GMWD premiums are paid to PSI, Inc., and are due one month prior to the month of coverage. The address for payment of a GMWD premium is P.O. Box 162348 Atlanta, Ga. 30348-2348.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: ABD Medically Needy Effective Date: July 2024 Chapter: 2100 Policy Number: 2150 Previous MT Number(s): MT 71 Updated or Reviewed in MT: MT-72

ABD Medically Needy (AMN) is a class of assistance (COA) that provides Medicaid coverage for aged, blind, or disabled individuals whose income and/or resources exceed income and resource limits for all other ABD Medicaid COAs.

There are two types of Medically Needy cases.

De Facto eligible occurs when the A/R’s net countable income is less than or equal to the ABD Medically Needy Income Level (AMNIL) and resources are less than or equal to the AMN resource limit.

Spenddown eligible occurs when the A/R’s net countable income is greater than the AMNIL. The amount of income greater than the AMNIL, called the spenddown, is offset by incurred medical expenses. Resources must also be less than or equal to the AMN resource limit.

AMN coverage is potentially available to aged, blind, or disabled individuals who have been determined to be financially ineligible under all other ABD Medicaid COAs. Eligibility for all other ABD Medicaid COAs except Q track and SSI must be ruled out before determining eligibility under AMN.

The resource limit used for an AMN individual is the SSI Individual resource limit.

The resource limit used for an AMN couple or an AMN individual with an ineligible spouse is twice the SSI Individual resource limit.

In AMN, the review period is for six months. Each month of the six-month review period is a separate budget period. Eligibility is determined for each month individually. The review period begins on the first day of the month in which the application is filed and runs through the last day of the sixth consecutive month.

For three months prior, each month is also a separate budget period.

If the A/R’s monthly countable income is equal to or less than the AMNIL, the A/R is De Facto eligible for Medicaid. Eligibility begins on the first day of the month.

If the A/R’s monthly countable income is greater than the AMNIL, the excess amount is called the spenddown.

This spenddown must be met before the A/R can be approved for Medicaid under AMN.

The spenddown is met by subtracting allowable medical expenses from the spenddown amount until the spenddown reaches zero.

When the spenddown is met, the A/R is considered spenddown eligible, and the A/R is approved for Medicaid effective the day spenddown is met through the end of the month.

The following individuals' medical expenses can be used in meeting the spenddown:

the A/R

the A/R’s legal ineligible spouse

the A/R’s non-legal ineligible spouse only if the second potential spenddown is used as the AMN spenddown

the A/R’s ineligible child

the A/R’s ineligible parent if the A/R is a child

the deceased spouse or child of the A/R if the A/R remains liable for payment of the bill

the child of the A/R who has reached 18 years of age if the child was under 18 at the time the medical expense was incurred, and the A/R remains liable for the bill. The child does not have to be currently living in the home with the A/R.

Medical expenses are used to meet the spenddown if they meet all of the following conditions:

The bill is unpaid as of the first day of the month or is incurred or paid during the budget period.

The A/R or deemor is legally obligated to pay the expenses of the people listed on page 2150-2.

There is no third-party liability (TPL) that is liable for payment of the expense. Refer to Special Considerations in this section and Chart 2150.1 – Allowable Medical Expenses for AMN . VA Aid and Attendance is NOT a TPL.

The bill is medically necessary. Any expense ordered or prescribed in writing by a medical practitioner recognized under state law is medically necessary. Doctor and hospital services are considered medically necessary.

The spenddown may be met using medical expenses incurred prior to the month. If this occurs, the A/R is eligible from the first day of the month.

If the spenddown is not met by previously incurred bills, the case is placed in suspense until enough bills are incurred to meet the spenddown or until the end of the month, whichever occurs first.

If the spenddown is met during the month, a first day liability (FDL) is computed for the day the spenddown is met. The A/R is responsible for paying this FDL. Form 400, Medically Needy First Day Liability, is used to inform the provider that the A/R is responsible for the FDL.

If an A/R submits a medical expense after the expiration of the budget period, the bill can be used to meet or adjust the SD for the expired budget period only if it is submitted within three months of the expired period, unless Good Cause exists.

If an A/R becomes eligible under another COA during a month while the case is in suspense, change the COA and begin eligibility effective the first day of that month.

Medicaid eligibility begins on a specific day in the month. This day is called the Begin Authorization Date (BAD).

Medical expenses incurred prior to the BAD in a month will not be paid by Medicaid. The BAD can be any one of the following dates:

the first day of the month if De Facto eligibility is established

the first day of the month if the spenddown is met using only unpaid medical bills incurred prior to the month

the day in the month in which the spenddown is met using bills incurred during the month or a combination of bills incurred during and prior to the month. (This day could also be the first day of the month.)

Screen for eligibility for SSI and all other classes of ABD Medicaid.

AMN may be processed if the A/R is financially eligible for SSI and has an approved SMEU decision.

Follow the steps below to establish eligibility for ABD Medicaid under AMN.

Step 1 Accept the Medicaid application from the A/R and establish the six-month review period. Obtain a written statement of choice when a bill that could potentially be paid by Medicaid is used to meet SD for an ongoing month. Step 2 Conduct an interview. A phone interview is required for AMN applications. Determine all basic eligibility criteria except length of stay (LOS) and level of care (LOC). Complete Form DMA-285, Third Party Liability (TPL), if a resource exists that will pay for all or a portion of the A/R’s medical expenses. Step 3 Establish financial responsibility. Refer to 2500 ABD Financial Responsibility and Budgeting Overview Chapter 2500 ABD Financial Responsibility and Budgeting, to determine the following: whose income and resources to consider which AMNIL and AMN resource limit (individual or couple) to use which eligibility budget to complete. Step 4 Determine the countable resources of the A/R and/or deemor for the first month of the review period and all requested prior months and compare to the appropriate resource limit to determine resource eligibility. Step 5 Determine the income for the A/R and/or deemor. Step 6 De Facto Eligibility. If the A/R’s net countable income is less than or equal to the appropriate AMNIL, the A/R is De Facto eligible. Approve the A/R for Medicaid effective the first day of the month. If the case is not De Facto eligible, proceed to Step 7. Step 7 Spenddown Eligibility. If the A/R’s net countable income exceeds the appropriate AMNIL, the amount of the excess is the spenddown. Explain the spenddown concept to the A/R. Step 8 Determine whose expenses may be allowed as a deduction from the spenddown. Refer to Basic Considerations in this section. Step 9 Obtain copies of any unpaid medical expenses and those paid during the month for the individuals determined in Step 8. The A/R has the option to use the unpaid medical bill for the month incurred or in a subsequent month. If the A/R submits unpaid medical bills and wants them used in a spenddown budget other than the month in which it was incurred, have them complete and sign the Medically Needy Option Statement, which may be found in Appendix F - Forms. A large unpaid bill may be used as a rollover bill for consecutive or non-consecutive months. If a TPL exists, determine how much the TPL will pay on these bills and subtract this amount from the bill. Deduct only the remaining amount from the spenddown. Do not delay an eligibility determination simply because TPL cannot be ascertained or payment of the third party has not yet been received. This includes pending lawsuits/legal issues as long as the legal proceedings are reported to the TPL unit. Once verification of the TPL is received, reconcile the SD budget, and make adjustments if it is to the advantage of the A/R. Refer to Special Considerations and to Chart 2150.1 – Allowable Medical Expenses for AMN . If the A/R is a self-payer for the Medicare premium, allow the premium as the first deduction for each month of the review period. This is an exception to the policy of deducting bills in chronological order. The Medicare premium can be deducted the first of each month even if the A/R has other deductible bills incurred prior to the first of the month. Keep copies in the document imaging system of all medical bills used in the SD budget to prevent reuse of bills in subsequent SD budgets. Step 10 Arrange the allowable medical expenses in chronological order by date incurred, oldest to most recent. Deduct from the spenddown allowable medical expenses incurred prior to the month in chronological order. If the spenddown is met using prior medical expenses, approve Medicaid for the A/R from the first day of the budget period. Notify the A/R, PR, and DCH via the system of eligibility dates and first day liability. Do not send a Form 400 to DCH. If the spenddown is not met, proceed to Step 11. Step 11 Deduct from the spenddown allowable medical expenses incurred during the month in chronological order. Rank medical expenses incurred on the same day as follows: expenses incurred by an ineligible spouse or ineligible child expenses incurred by the A/R but not covered by Medicaid (non-covered items such as over-the-counter drugs or bills payable to non-Medicaid providers) remaining expenses, low to high, incurred by the A/R that are payable to a Medicaid provider. If the spenddown is met, proceed to Step 12. If the spenddown is not met, proceed to Step 14. Step 12 If the spenddown is met by bills in ranking order 1 or 2, Form 400 is not required. Complete the following actions: Approve the A/R for Medicaid to begin on the day in which the bill that brought the spenddown to zero (the break-even bill) was incurred. Send notice to the A/R. Include the BAD, the ending date of eligibility and the A/R’s Medicaid number. Complete Form 962 for any months you are unable to enter in the system. Enter $0 as the First Day Liability Amount. If the spenddown is met by bills in ranking order 3, Form 400 is required. Complete the following actions: Issue a Form 400 for the break-even bill showing the amount of the bill that was applied to the spenddown as the client liability. The Form 400 can be issued to either the A/R or to a provider. Discuss with the A/R and determine to whom the Form 400 should be issued. Issue Form 400 with a client liability of zero for any other Medicaid covered bills incurred on the BAD that were not used to meet the spenddown. The Form 962 must contain the following: “Form 400 Required”- “Y” The amount of the First Day Liability (FDL) Pharmacy is Break-even bill – “Y” or “N” “Eff Date” and “End Date” are the month, day, and year of the beginning and ending dates of eligibility. For group practices, indicate the specific individual who performed the medical service on Form 400, not the group name. Hospitals often submit a consolidated bill to the A/R. If requested to do so, issue Form(s) 400 to any individual provider whose bill was included in the consolidated bill. Include the FDL on the Form 400 for the hospital, but not on the Form 400 for the individual provider. Send notice to the A/R, including the BAD, FDL and the A/R’s Medicaid number. Step 13 If the spenddown is not met, place the case in suspense until enough medical expenses are incurred to meet the spenddown. Step 14 Subtract verified allowable medical expenses from the spenddown as they are presented by the A/R using Step 11 ranking order. Step 15 Deduct any medical expenses incurred during the month as they are provided by the A/R. Step 16 If the spenddown is met during the month, approve Medicaid as of the day spenddown is met. If the spenddown is not met during the month, begin the spenddown determination for the next month.

The following expenses can be used to meet the AMN spenddown:

Services provided by the following: Chiropractors Dentists Hospitals LPNs Medical Clinics Mental Health Clinics MR Group Homes (daily rate for treatment and training) Nursing Assistants Opticians Optometrists Osteopaths Oculists Personal Attendants (sitters) – obtain doctor’s statement that a personal attendant/sitter is necessary for A/R’s medical condition Physicians Psychiatrists RNs

Medical care purchases, such as the following: medical tests hearing aids eyeglasses contact lens dentures prescription drugs over-the-counter medical needs transportation costs to obtain medical services – the lesser of actual cost or maximum allowable amount. (See Appendix A-1 for maximum allowable mileage costs) prosthetic devices immunizations Guide Dog or other animal trained to assist a physically disabled person (include the cost of securing and maintaining animal)

Elective surgery

Medically necessary ambulance service

Health and/or dental insurance premium. If a fee or premium is paid by an entity other than the A/R, such as the Federal or state government, it is NOT treated as a medical expense for AMN.

A prescription drug that is NOT covered on an A/R’s Medicare Part D plan may only be allowed as a medical expense for AMN if the A/R provides verification that s/he has gone through the appeals process with their plan’s carrier and has received an unfavorable decision.

The following medical expenses may be projected (rather than used as a daily expense) as billed/paid for applying to the AMN spenddown: personal care home (with doctor’s statement - medical expense portion only, room and board expenses are not allowable) NH bill Personal sitter (with doctor’s statement only) The projected medical bills of personal care home, NH, and personal sitter will not be paid by DCH.

These lists are not all inclusive. Explore TPL coverage before applying any medical expense as a deduction from the spenddown. If the medical bill is questionable as to whether or not it is allowable, follow the procedures outlined in Section 2555-3 to submit IMEs for approval.

Verify incurred medical expenses by one of the following:

Medical bills or statements

Receipts for payment of medical expenses

Medical Explanation of Benefits (EOB) which shows covered/non-covered and paid/unpaid medical expenses

Health insurance statements showing amount paid

Odometer readings for mileage costs

Other appropriate means

A doctor’s statement (written or verbal) indicating anticipated Medicare TPL may be used as verification until such time as the Medicare EOB is received.

If a previously “written off” bill is submitted again as owed, do not allow this bill to be used in the spenddown budget. Writing a bill off gives the provider of service a tax benefit and makes them eligible for Indigent Trust funds.

Use the following chart to determine which medical expenses can be deducted to meet the spenddown in an AMN case:

Chart 2150.1 – Allowable Medical Expenses for AMN ALLOWABLE NOT ALLOWABLE Medical bills belonging to individuals who are or could have been included in the BG when the expenses were incurred. Unpaid bills that the A/R or deemor remains liable for paying. If there is a deductible or co-payment amount to be paid by the A/R, this can be allowed. However, if a decision is pending as to who is liable, do not allow the deduction until the decision on liability is made. If a bill is paid in full or in part to a provider or as a reimbursement to the A/R or deemor by a public program funded by the state or programs of political subdivisions of the state, allow this as a deduction in the month incurred or paid, as long as no federal funds are used. Verify the source of the funding to ensure that there are no federal funds. Allow a reimbursement for this third party only if the bill was paid by the A/R and reimbursed in the same month. Do not allow the bill as a deduction if the A/R paid the incurred expenses prior to the current month and was reimbursed in the current month. Unpaid bills incurred prior to the month which were not used to meet a spenddown for another month. Bills incurred during the month, whether paid or unpaid. Bills applied to an earlier spenddown that was never met if the bills are still owed and the individual who incurred them is still a deemor or A/R’s minor child. Medical bills used in ARM AMN budgets in the spenddown process. Bills not presented to the worker during the month provided the A/R or deemor remains liable for payment as of the first day of the next month under consideration. The remainder of unpaid bills incurred prior to the month that have been turned over to a collection agency. If these medical bills are consolidated with other bills, only the portion that can be verified as unpaid medical expenses can be deducted. Monthly payments to a collection agency cannot be deducted. Medical expenses related to pregnancy, including prepayment of delivery fees or admission fees by the hospital when billed. Medical bills past or present which are/were subject to payment by a third-party liability (TPL), including Medicare. Exception: See Step 9 regarding legal issues. VA Aid and Attendance is not a TPL. Medical bills incurred in a month in which the A/R was Medicaid eligible that were not submitted to DMA or not submitted timely for payment, or which were submitted and rejected for errors in filing the claim. For ongoing AMN, past medical debts which were forgiven or written off by the provider prior to the first day of the month or prior to the date the case is brought to final disposition. Medical expenses paid by Medicaid under three months prior coverage. Medical bills applied in another month in which spenddown is met. Long term care medical bills incurred by A/R who is not found eligible for Medicaid under an LA-D COA due to a transfer penalty, may not use those bills as an expense for AMN. Emergency Medical Assistance COA: Bills from any time period can be used as long as the A/R or deemor still has a legal obligation to pay the bill. The incurred bills are not limited to the time of the emergency service. Medical bills that have been paid with the proceeds of a loan if the loan has not been fully repaid. If other expenses were also paid by the loan, consider any and all payments made on the loan to be for the medical bills. Medicare premiums for an A/R who is a self-payer are deductible the first day of each month, even if A/R is eligible as of the first day of the month using bills from previous months. Medical bills that may potentially be paid as the result of a pending lawsuit/legal issue are allowable in the month the bill is incurred. However, complete and send a Form DMA 285 regarding the pending lawsuit. A prescription drug that is NOT covered on an A/R’s Medicare Part D if the A/R provides verification that s/he has received an unfavorable decision from the carrier that it will not be covered. Medicare Part D premiums and co-pays until such time as they are picked up by Medicaid. This should occur annually within two months after the first month of AMN approval. Any prescription that is covered under Medicare Part D (excluding co-pay). Once the A/R has met SD, do not allow any prescription payments or co-pays from that point to the end of the month. These should be covered by Medicaid.

Since AMN eligibility is determined for a time limited review period, the AMN case must be reviewed at the beginning of each new review period.

Complete a full eligibility determination with the A/R’s first application, including a signed application, other basic eligibility criteria and full verification as required for an initial application under any other ABD Medicaid COA.

For each successive review period on a case that has continued in an active or suspense status, complete a review of eligibility using the procedures in 2706 Medicaid Renewals . It is not necessary to complete another application unless the case has been closed for an entire month or more.

If a SMEU decision is used to verify disability at the point of an initial AMN application, the SMEU decision is verification of disability for all successive AMN applications unless SMEU requests a review of disability.

The SOP for an AMN application is met when all basic and financial eligibility criteria are met, and the A/R is either notified in writing of the amount of the spenddown, or the A/R is approved if spenddown is already met.

An individual who is eligible for ongoing QMB, SLMB or QI-1 does not have to file a separate application for AMN. The A/R must make his/her intentions known by requesting AMN verbally or by a written statement. Document the case record accordingly. If the A/R submits medical bills not covered by Q Track, consider it a request for AMN.

Determine AMN eligibility for:

the month the bill is received by the case worker OR

any of the three prior months OR

the ongoing month.

The medical bill has to meet all criteria for being an allowable deduction for the month under consideration.

A Q Track application filed on a DCH Form 700 may also be used as an application for full Medicaid benefits. However, additional information and verification may be required for full Medicaid.

TYPE OF CASE BAD FDL 400s REQUIRED TRANSMIT ELIGIBILITY VIA 962 to A/R De Facto First Day of BP $0 NONE System See note SD: Unpaid break-even bill incurred prior to BP First Day of BP $0 None System See note SD: Unpaid Medicaid covered, break-even bill incurred by A/R during the BP Date of break-even bill Amount of break-even bill applied to SD Break-even bill and any other of A/R’s Medicaid covered bills incurred on BAD, but not needed to meet SD System See note SD: Break-even bill not covered by Medicaid and incurred during BP Date of break-even bill $0 NONE System See note

The system generated notice, which includes Medicaid eligibility information, replaces Form 962. Complete a Form 962 only if eligibility cannot be entered in the system, such as a three-month prior application that is greater than thirteen months old.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Family Medicaid Overview Effective Date: August 2025 Chapter: 2100 Policy Number: 2160 Previous MT Number(s): MT 70 Updated or Reviewed in MT: MT 76

Family Medicaid provides Medicaid benefits for low-income families and individuals who are not receiving SSI and may or may not be receiving Temporary Assistance to Needy Families (TANF). Benefits are provided through a variety of classes of assistance (COA’s), each with its own specific eligibility criteria.

Effective January 1, 2014, Family Medicaid will be comprised of two groups; the Modified Adjusted Gross Income (MAGI) COAs and the Non-MAGI COAs.

Family Medicaid Non-MAGI Assistance Units (AUs) include:

Newborn

Family Medically Needy

Pregnant Medically Needy

Refugee

Foster Care

Adoption

CHAFEE

Women’s Health Medicaid

Family Medicaid MAGI AUs include:

Parent/Caretaker with Child(ren)

TMA/4MEx

Pregnant Women

Children Under 19 Years of Age

Georgia Pathways to Coverage™ (Pathways)

Planning for Healthy Babies® (P4HB)

Former Foster Care Medicaid

Family Medicaid AUs must meet specific Basic Eligibility Criteria:

age

citizenship/immigration status

cooperation with DCSS

enumeration

identity

residency

third party liability

specified relative relationship/tax filer/non-filer status

Each COA has different exceptions to the Basic Eligibility Criteria. Refer to Chapter 2200 - Basic Eligibility Criteria and to each COA in this chapter.

A pregnant woman who is eligible for and receiving Medicaid under any Medicaid COA (except Q-track, P4HB or a Family Medicaid Medically Needy in suspense) or SSI on the date the pregnancy terminates is eligible to continue to receive the 12-month extended postpartum period. The 12-month extended postpartum period count begins the month after the termination of pregnancy. Medicaid continues through the last day of the 12 th month.

Medicaid coverage under any Medicaid COA (except Q-track, P4HB or Family Medicaid Medically Needy in suspense) or SSI is continued for a pregnant woman who, after approval becomes financially ineligible solely because of new income or a change in income of any BG member. The pregnant woman remains eligible for Medicaid for the remainder of the pregnancy, including the 12-month extended postpartum period. Refer to Section 2720 - Continuous Coverage for Pregnant Women .

If a pregnant woman meets spend down for at least one month during their pregnancy or in the pregnancy termination month, the pregnant woman is eligible for the 12-month extended postpartum period. Eligibility for any Family Medicaid COA can begin with the month of application and can include up to three months prior to the month of application. All points of eligibility for that COA must be met in each of the three prior months. Refer to Section 2053 - Retroactive Medicaid .

Pathways does not allow for retroactive coverage.

Three months retroactive Medicaid does not pertain to January 2014 applications for MAGI COAs.

Under certain conditions, Medicaid may cover services rendered to Medicaid-eligible Georgia residents who are out of state when medical services are provided. Procedures for qualifying for out-of-state coverage are found on the back of the Medicaid card.

All Family Non-MAGI Medicaid cases are budgeted using prospective income and expenses.

All Family MAGI Medicaid cases are budgeted using prospective income.

Eligibility for three months prior Family Medicaid is determined using actual income and expenses. If available, actual income may be used for intervening months. Data sources and/or related active programs verification must be accessed for all MAGI Medicaid COAs prior to requesting verification.

For Family Non-MAGI Medicaid COA’s, if resources of the BG are within the applicable resource limit at any time during a month, the AU is resource-eligible for that month.

There are no resource requirements for MAGI Medicaid COAs.

A Family Medicaid case that is ineligible because of financial reasons for one month only is suspended, not terminated. Refer to Sections 2700 - Case Management Overbiew , 2712 - Family Medicaid Changes Overview , 2714 - Family Medicaid AU/BG Composition Changes , 2715 - Family Medicaid Changes in Income and 2716 - Family Medicaid Miscellaneous Changes .

MAGI COAs use the MAGI based income methodology.

Family Medicaid applications are accepted at the following sites:

Federally Facilitated Marketplace (FFM) (Obsolete 12/2024)

Georgia Access

County DFCS offices

DFCS Project outreach locations

Department of Public Health offices

Public medical facilities

Federally funded health care centers

Disproportionate-share hospitals

Gateway

Refer to Section 2050 - Application Processing Overview .

Presumptive Eligibility (PE) is determined by Qualified Providers (QPs) and Qualified Hospitals (QHs) certified by the Department of Community Health (DCH). PE is a temporary eligibility determination and is available to pregnant women, parent/caretakers with children under age 19, children under age 19, former foster care children and women in treatment for breast or cervical cancer. If an individual is determined eligible for PE, a temporary Medicaid Certification is issued by the QP/QH. A PE Packet is completed concurrently and routed to DFCS for processing. Refer to Sections 2050 - Application Processing Overview , 2065 - Family Medicaid Application Processing , 2067 - Presumptive Eligibility Medical Assistance for additional information regarding PE.

The Medicaid application process begins with a request for assistance and ends with notification to the AU of the eligibility decision. Refer to Section 2050 - Application Processing Overview for additional information.

A Continuing Medicaid Determination (CMD) is required before denying a Medicaid application or terminating Medicaid under the current COA. A CMD is the determination of Medicaid eligibility under all COA’s. Refer to Section 2050 - Application Processing Overview and Section 2700 - Case Management Overview for additional information.

At application and renewal, contact the A/R to inquire if any AU member is pregnant. If an AU member is pregnant, Gateway will send a follow-up contact with the pregnant woman during the month prior to the Estimated Delivery Date (EDD).

Health check services information for all Medicaid recipients under age 21 is referenced on Gateway notices. Refer to Section 2930 - EPSDT Services for additional information.

Refer the following to the Department of Public Health for services under the Women, Infant and Children (WIC) Program :

pregnant women

women who are breast feeding through the first twelve months after the birth of a child

children under age five

post-partum women for six months from the termination of pregnancy Refer to Section 2985 - Women, Infant and Children (WIC) Services for additional information.

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Parent/Caretaker with Children Effective Date: August 2025 Chapter: 2100 Policy Number: 2162 Previous MT Number(s): MT 58 Updated or Reviewed in MT: MT 76

Parent/Caretaker with Child(ren) provides Medicaid benefits for eligible children under the age of 19, and the eligible adult(s), who meet the tax filer or non-tax filer status for the child(ren).

Assistance Unit (AU) members must meet the following basic eligibility requirements:

Age – A child must be under the age of 19 to be eligible. There is no age requirement for adult AU members. Refer to Section 2255 - Age (Family Medicaid) .

Citizenship/Immigration/Identity status - Each AU member must be a U.S. citizen or meet immigration eligibility requirements. Refer to Section 2215 - Citizenship/Immigration/Identity .

Enumeration - The A/R must furnish, apply for, or agree to apply for a Social Security Number (SSN) for each AU member, unless Good Cause is established.

An adult who does not meet this requirement, without Good Cause, is penalized. The child(ren) in the AU that does not meet this requirement, without Good Cause, is excluded from the AU. Refer to Section 2220 - Enumeration .

Child Support Services (DCSS) - The AU must cooperate with DCSS in the attempt to obtain medical support from the absent parent (AP), unless Good Cause is established. A referral to, and cooperation with Child Support Services (DCSS) is; however, NOT a requirement for child-only Medicaid cases.

A child-only Medicaid case is defined as a Medicaid AU in which no adults are receiving Medicaid. An AU which contains a penalized adult is NOT considered a child-only case.

The AP of a child included in a Parent/Caretaker with child(ren) AU is not referred to DCSS if the AP provides health insurance for the child, unless the A/R wishes to pursue collection of child support monies.

An adult who does not cooperate with DCSS, without Good Cause, is penalized. Refer to Section 2250 - Cooperation with Division of Child Support Services .

Tax Filer and Non-Tax Filer Status - Individuals expected to be included on the next tax return filed are potentially eligible to receive MAGI Medicaid. Individuals that meet non-tax filer criteria are potentially eligible to receive MAGI Medicaid. Refer to Section 2245 - Living With A Specified Relative/Tax Filer/ Non-Tax Filer .

SSI recipients must be included in the budget group for MAGI COAs, but the income of the SSI recipients will not be counted in the budget. Refer to Section 2610 - MAGI Budget Groups / Assistance Units .

Residency - AU members must be residents of Georgia. Refer to Section 2225 - Residency .

Third Party Liability Requirements - The A/R is required to provide information regarding any Third Party Liability (TPL) available to any AU member. The A/R must assign his/her TPL rights to DCH, unless Good Cause exists.

An adult who does not meet this requirement, without Good Cause, is penalized. Refer to Section 2230 - Third Party Liability .

Although Application for Other Benefits is not an eligibility requirement for Medicaid, the A/R should be notified of potential benefits if applicable.

AU’s must have income within the following limit:

Modified Adjusted Gross Income (MAGI) - The total taxable net income of the AU must be equal to or less than the MAGI income limit of the AU size. Refer to Appendix A2 - Financial Limits for Family Medicaid TOC .

Prospective budgeting is used in determining eligibility for the application month and the ongoing benefit period. If available, actual income may be used for intervening months. Data sources and/or active related programs verifications are used prior to requesting verification.

Actual income is used to determine eligibility for retroactive three (3) months prior Medicaid. Refer to Section 2053 - Retroactive Medicaid .

Modified Adjusted Gross Income (MAGI) financial methodologies are used to calculate the monthly MAGI income used for the BG. Pre-tax deductions and 1040 deductions are given. Refer to Section 2669 - MAGI Budgeting .

MAGI income deduction is 5% of the 100% Federal Poverty Level (FPL) of the AU size. Refer to Section 2669 - MAGI Budgeting .

Georgia Division of Family and Children Services Medicaid Policy Manual Policy Title: Transitional Medical Assistance (TMA) Effective Date: June 2025 Chapter: 2100 Policy Number: 2166 Previous MT Number(s): MT 73 Updated or Reviewed in MT: MT 74

Transitional Medical Assistance (TMA) provides continued Medicaid coverage for up to 12 months for Parent/Caretaker with Child(ren) AUs that become ineligible because of changes related to earned income.

To be eligible for continued Medicaid coverage under TMA, the AU must have correctly received Parent/Caretaker with Child(ren) in three of the six months preceding the first month of Parent/Caretaker with Child(ren) ineligibility. An AU is potentially eligible to receive TMA for 12 months beginning with the first month following the last month of Parent/Caretaker with Child(ren) Medicaid.

To be eligible for continued Medicaid coverage under TMA, Medicaid ineligibility must result exclusively from new or increased Modified Adjusted Gross Income (MAGI) earnings of an adult AU member or child AU Member with earnings above the allowable IRS dependent exemption, referred herein as a "TMA-qualifying event."

TMA-qualifying event includes any of the following:

new employment

increase in earnings as a result of an increase in hours worked

increase in salary or hourly wage

earnings of an eligible member added to the AU

decrease in pre-tax or 1040 deductions

Ineligibility may be caused by new or increased earnings and a concurrent change. If the concurrent change alone caused ineligibility, the AU is ineligible for TMA.

Cooperation with Third Party Liability (TPL) is required at approval for TMA as well as during both 6-month review periods. Refer to Section 2230 - Third Party Liability .