GROUP

BENEFITS BASIC MEDICAID ELIGIBILITY REQUIREMENTS**

SPECIAL PROVISIONS EFFECTIVE 07/2025 BASIC ELIGIBILITY REQUIREMENT WHOSE INCOME and RESOURCES COUNT MONTHLY INCOME LIMIT Updated 04/2026 RESOURCE LIMIT Updated 04/2026

DEDUCTIBLE/SPEND DOWN S-ABD, SSI cases Full Medicaid coverage only if a Medicaid application is submitted • Beneficiaries receiving Supplemental Security Income (SSI) -Federal cash assistance program for the aged, blind, and disabled, are automatically entitled to Medicaid. No separate application or Medicaid determination is required. • Beneficiaries receiving State/County Special Assistance (SA) - program for aged and disabled individuals who are primarily in adult care facilities- includes Medicaid eligibility. • Beneficiaries receiving Special Assistance In-Home- the individual must be determined Medicaid categorically needy eligible.

Aged MAA Full Medicaid Coverage Age 65 or older Spouse’s income and resources if live together 100% of Poverty Level 1 – $1,330 2 – $1,804 SSI Limits 1 - $2,000 2 - $3,000 YES If income exceeds income limit and the indicator is “yes,” the individual or family may be able to be eligible for Medicaid if they can meet a deductible. See discussion of Medical Deductible on page 2 of this same column.

Individuals in nursing facilities generally do not have to meet a deductible to be eligible for Medicaid. However, they must pay all of their monthly income, less a $70 personal needs allowance and the cost of medical expenses not covered by Medicaid or other insurance to the nursing facility. Medicaid pays the remainder of their cost of care. Protection of income for spouse at home: When an individual is in a nursing facility and has a spouse living at home, a portion of the income of the spouse in the facility may be protected to bring the income of the spouse at home up to a level specified by federal law. Currently, that amount is $2,643.75/mo. and can be as much as $3,948.00 depending upon at-home spouse’s cost for housing. The amount protected for the at-home spouse is not counted in determining the eligibility of the spouse in the nursing facility.

Protection of resources for spouse at home: Additionally, the countable resources of the couple are combined and a portion is protected for the spouse at home. That portion is ½ the total value of the countable resources, but currently not less than $31,584 or more than $157,920. The amount protected for the at-home spouse is not countable in determining the eligibility of the spouse in the facility.

Transfer of resources: When a person gives away resources and does not receive compensation with a value at least equal to that of the resources given away, he may be penalized. Medicaid will not pay for care in a nursing facility or care provided under the Community Alternative Program (CAP) or other in-home health services & supplies for a period of time that depends on the value of the transferred resource. Blind MAB Full Medicaid Coverage Blind by Social Security Standards Spouse’s income and resources if live together. Parents’ income and resources if under age 18 and live with parents. 100% of Poverty Level 1 – $1,330 2 – $1,804 SSI Limits 1 - $2,000 2 - $3,000 YES Disabled MAD Full Medicaid Coverage Disabled by Social Security Standards Spouse’s income and resources if live together. Parents’ income and resources if under age 18 and live with parents. 100% of Poverty Level 1 – $1,330 2 – $1,804 SSI Limits 1 - $2,000 2 - $3,000 YES Health Care for Working Disabled (HCWD) MAD Full Medicaid Coverage For Basic Coverage, the beneficiary does not have to meet the Social Security SGA requirement to be disabled. For Medically Improved coverage, the beneficiary does not have to meet the Social Security medical requirements for disability. Spouse’s income and resources if live together. Parents’ income and resources if under age 18 and live with parents. 150% of Poverty Level 1 - $1,995 2 -$2,705

200% of Poverty Level 1 - $2,660 2 - $3,607

Min. CSRP limit $32,532 NO Qualified Medicare Beneficiaries MQB-Q Payment of Medicare premiums and deductibles and co- insurance charges for Medicare covered services Entitled to Medicare Parts A & B Spouse’s income and resources if live together. Parents’ income and resources if under age 18 and live with parents. 100% of Poverty Level 1 – $1,330 2 – $1,804 1 - $9,950 2 - $14,910 NO Specified Low Income Medicare Beneficiaries MQB-B Payment of Medicare Part B premium Entitled to free Medicare Part A Spouse’s income and resources if live together. Parents’ income and resources if under age 18 and live with parents. 120% of Poverty Level 1 - $1,596 2 - $2,164

1 - $9,950 2 - $14,910 NO Qualifying Individual MQB-E Payment of Medicare Part B Premiums Entitled to free Medicare Part A Spouse’s income and resources if live together. Parents’ income and resources if under age 18 and live with parents. 135% of Poverty Level 1 - $1,796 2 - $2,435 1 - $9,950 2 - $14,910 NO NOTE: Total number of eligible individuals is limited to available funds. Working Disabled MWD Payment of Medicare Part A premiums

Lost entitlement to free Medicare A due to earnings but still has disabling impairment. Spouse’s income and resources if live together. Parents’ income and resources if under age 18 and live with parents. 200% of Poverty Level 1 - $2,660 2 - $3,607 2X SSI Limits 1 - $4,000 2 - $6,000 NO Traumatic Brain Injury (TBI) Full Medicaid Coverage Age 18 and older and eligible for MAABD or SAABD Spouse’s income and resources if live together. 300% of Poverty Level 1-$3,990 2-$5,410 SSI Limits 1 - $2,000 2 - $3,000 NO

GROUP BENEFITS BASIC MEDICIAD ELIGIBILITY REQUIREMENTS ** Notes BASIC ELIGIBILITY REQUIREMENT WHOSE INCOME and RESOURCES COUNT MONTHLY INCOME LIMIT Updated 04/2026 RESOURCE LIMIT Updated 04/2026 DEDUCTIBLE/SPEND DOWN Families & Children MAF

Full Medicaid Coverage Parents/Caretaker Relatives, and the spouse must be living with and caring for a child to whom they are related who is under age 18. Children must be under age 21. MAGI Methodology.

1 - $434 2 - $569 3 - $667 4 - $744 5 - $824 NO YES If income exceeds income limit and the indicator is “yes” the individual or family may be able to be eligible for Medicaid if they can meet a deductible

Medicaid Deductible: When an individual/family is ineligible for Medicaid due to income over the income limit, they may become eligible by meeting a Medicaid deductible. The deductible is determined by subtracting the Medically Needy Income Limit (MNIL) (see limits below) from the countable monthly income to determine the monthly excess income. Medicaid deductibles are generally determined for 6 months, so the monthly excess income is multiplied by 6 to determine the 6-mo. deductible. Once medical bills for which they are responsible totaling the amount of the deductible are incurred, they are authorized for the rest of the 6-mo. period. Medicaid cannot pay for any of the bills applied to the deductible.

Pregnant Women MPW

Full Medicaid A self-attestation of pregnancy and due date can be accepted as proof of pregnancy unless the county has information that contradicts the attestation. MAGI Methodology 196% of Poverty Level 1 - $2,607 2 - $3,535 3 - $4,463 4 - $5,390 5 - $6,318 NO NO When determining the family size for the pregnant woman the unborn child is included. For example, the family size for a single pregnant woman would be 2. Children age 0 thru 18 MIC Full Medicaid Coverage Must be age 0 thru age 18. MAGI Methodology 211% of Poverty Level 1 - $2,807 2 - $3,806 3 - $4,804 4 - $5,803 5 - $6,802 NO NO

Title IV-E Children IAS Full Medicaid Coverage IV-E Adoption Subsidy and Foster Care for a child residing in NC and receiving IV-E Foster Care regardless of the state providing assistance. There is no income.

NO NO MNIL: 1 - $242 2 - $317 3 - $367 4 - $400 5 - $433 Resource limit: All deductible cases have a resource limit: $3,000 for families and children and $2,000 (1) and $3,000 (2) for aged, blind and disabled.

State Foster Care Children Full Medicaid Coverage A child under 21 and currently in the legal custody of the state sponsored foster care and ineligible for Title IV-E. MAGI Methodology 1. MAGI 2. MAF-M

$3,000 (MAF-M) YES

Expanded Foster Care Full Medicaid Coverage Be 18-20 and had been in Foster Care at age 18 and enrolled in Medicaid program. MAGI Methodology 1. MAGI 2. MAF-M $3,000 (MAF-M) YES

GROUP BENEFITS BASIC MEDICAID ELIGIBILITY REQUIREMENTS ** Notes BASIC ELIGIBILITY REQUIREMENT WHOSE INCOME and RESOURCES COUNT MONTHLY INCOME LIMIT Updated 04/2026 RESOURCE LIMIT Updated 04/2026 DEDUCTIBLE/SPEND DOWN Non-IV-E/ Special Needs Adoption Full Medicaid Coverage Children with medical or rehabilitative needs, which are barriers to adoption are considered special needs adoption children. These children are ineligible through Title IV-E because at the time of placement in foster care they did not meet IV-E requirements. MAGI Methodology 1. MAGI 2. MAF-M 3. Authorize ongoing Medicaid (See Notes)

NO YES

If ineligible under MAGI, the child must have been enrolled in or eligible for Medicaid immediately before the adoption agreement, is under a Non-IV-E state adoption agreement or determined to be special needs by the State adoption assistance agreement.

MFC- Medicaid for Former Foster Care

Full Medicaid Coverage Be age 18-26 and have been in foster care at age 18 and enrolled in NC Medicaid. There is no income.

NO NO

Effective January 1, 2023: Individuals who turn age 18 that were in foster care and receiving Medicaid in any state. Breast & Cervical Cancer Medicaid MAF-W Full Medicaid Coverage Be under the age 65 and not enrolled in any creditable medical insurance. Breast and Cervical Cancer Control Program (BCCCP) provider determines eligibility for Breast and Cervical Cancer Medicaid (BCCM). There is no income (BCCM).

NO NO

Family Planning MAF-D

Family Planning Program NO AGE LIMIT MAGI Methodology 195% of Poverty Level 1 - $2,594 2 - $3,517 3 - $4,440 4 - $5,636 5 - $6,286 NO NO

If a beneficiary’s income increases to more than 195%, he/she will be ineligible for family planning coverage. Transitional Medicaid (TMA) Full Medicaid Coverage A beneficiary may receive up to twelve months of Transitional Medicaid (TMA) when ineligible for MAF-C because of new or increased income. MAGI Methodology 185% of Poverty Level 1 - $2,461 2 - $3,337 3 - $4,212 4 - $5,088 5 - $5,964 NO NO

Must have been eligible for MAF-C in North Carolina in at least three of the six months immediately preceding the first month of ineligibility. There must be an eligible child receiving Medicaid Medicaid Expansion (MXP) Full Medicaid Coverage Age 19 or over and under age 65. MAGI Methodology 133% of Poverty Level 1 - $1,769 2 - $2,399 3 - $3,028 4 - $3,658 5 - $4,288 NO NO

***This chart addresses benefits and basic eligibility requirements. Other requirements (such as citizenship/alien status, incarceration, & state residence) which can also affect eligibility, or the level of benefits are not reflected on this chart. Revised 4/1/2026

1 North Carolina Department of Health and Human Services North Carolina Medicaid Division of Health Benefits FAMILY AND CHILDREN’S MEDICAID MANUAL

FAMILY AND CHILDREN’S MEDICAID TABLE OF CONTENTS

REVISED 8/15/2023 – CHANGE NO. 11-23

MA-3100 Introduction MA-3110 Definitions MA-3120 SSI Medicaid MA-3185 Discouragement MA-3190 Inquiry MA-3200 Application MA-3205 Post Eligibility Verification MA-3207 Outstations MA-3217 Evaluating County/DDS Performance MA-3225 Application Processing-Corrective Action Procedures MA-3230 Auto Newborn MA-3231 Adoption Medical Assistance MA-3232 Foster Care Medical Assistance MA-3233 Former Foster Children (MFC) MA-3234 Expanded Foster Care Program (EFCP) MA-3235 Caretaker Relative/Kinship MA-3240 Pregnant Woman Coverage MA-3245 Presumptive Eligibility for Pregnant Woman MA-3246 Hospital Presumptive MA-3250 Breast and Cervical Cancer Medicaid (BCCM) MA-3260 Community Alternatives Program (CAP) Medicaid Eligibility MA-3262 Money Follows the Person MA-3263 Managed Care MA-3265 Family Planning Program MA-3270 Program Of All-Inclusive Care For The Elderly (PACE) MA-3300 Income MA-3305 MAF, MIC,HSF Budgeting MA-3306 Modified Adjusted Gross Income (MAGI) MA-3310 Reasonable Compatibility MA-3313 Sponsor Deeming MA-3315 Medicaid Deductible MA-3320 Resources MA-3321 MAGI Medicaid MA-3322 Community Spouse Resource Protection MA-3325 Long Term Care Budgeting

MA-3326 Estate Recovery MA-3330 Alien Requirements MA-3331 Citizenship/Identity SSA Data Match MA-3332 US Citizenship Requirements MA-3333 Tribal Membership and Indian Health Services (IHS) MA-3335 State Residency MA-3340 County Residence MA-3345 Age/Name/Marital Status MA-3355 Enumeration Procedures MA-3360 Living Arrangement MA-3365 Child Support MA-3400 Four Months Transitional Medicaid MA-3405 Twelve Months Transitional Medicaid MA-3410 Change in Circumstance, Terminations, and Reopening MA-3415 Classification and Evaluation MA-3420 Medically Needy Recertification MA-3421 MAGI Recertification MA-3425 Certification and Authorization MA-3430 Notice and Hearings Process MA-3435 Community Care of North Carolina/Carolina Access MA-3500 Confidentiality MA-3505 Medicaid Identification Card MA-3510 Third Party Recovery MA-3515 Automated Inquiry and Match Procedures MA-3520 Automated SOLQ Procedures MA-3525 Medicare Enrollment & Buy-In MA-3530 Corrective Action and Responsibility for Errors MA-3535 Recipient Fraud and Abuse Policy and Procedures MA-3540 Medicaid Covered Services MA-3550 Non-Emergency Medical Transportation (NEMT) MA-3560 Security of Internal Revenue Service and Social Security Administration Data Information

North Carolina Department of Health and Human Services Division of Medical Assistance Medicaid Eligibility Unit AGED, BLIND, AND DISABLED MEDICAID MANUAL

MA-200

DEFINITIONS

1 MA-200 DEFINITIONS

REVISED 11/01/07 – CHANGE NO. 25-07 I. ACRONYMS

AAF & AFDC Aid to Families with Dependent Children [now called Work First Family Assistance (WFFA) or Temporary Assistance to Needy Families] ADH Administrative Disqualification Hearing ALJ Administrative Law Judge AMA American Medical Association AOC Administrative Office of the Court AP Absent Parent APS Adult Protective Services APT Average Processing Time A/R Applicant/Recipient AS Adult Services or Adoption Subsidy ASVI Alien Status Verification Index AU Assistance Unit AV Actual Value BCCM Breast and Cervical Cancer Medicaid BCIS Bureau of Citizenship and Immigration Services (formerly known as Immigration and Naturalization Service) BEER Beneficiary Earnings Exchange Report BENDEX Beneficiary Data Exchange BEOG Basic Education and Opportunity Grant BH Boarding Home BU Budget Unit CAA Community Action Agency CAP Community Alternative Program CAP/C CAP for Children (Katie Beckett) CAP/CHOICE CAP Choice ICF and SNF CAP MR-DD CAP for Mentally Retarded - Developmentally Disabled C/S Client Statement DA Disabled Adult CC Child Care CD Certain Disabled CD-SA Certain Disabled - Special Assistance CFR Code of Federal Regulations CHIP Children’s Health Insurance Program (NCHC in North Carolina) CHS Community Health Services CIP Crisis Intervention Program

North Carolina Department of Health and Human Services AGED, BLIND, AND DISABLED MEDICAID MANUAL

MA-200

DEFINITIONS

2 REVISED 11/01/07 – CHANGE NO. 25-07 (I.) CMS Centers for Medicare and Medicaid (formerly HCFA) CMV Current Market Value CN Categorically Needy CN-NMP Categorically Needy - No Money Payment COC Cost of Care COLA Cost of Living Adjustment CP Certification Period CPI Continuous Period of Institutionalization CPS Child Protective Services CSC Clerk of Superior Court CSRP Community Spouse Resource Protection CTC Child Tax Credit CUSP Community Spouse CWS Child Welfare Services DA Disabled Adult DAC Disabled Adult Child DBA Doing Business As DDS Disability Determination Services DEC Developmental Evaluation Center DENR Department of Environmental and Natural Resources DHHS Department of Health and Human Services DMA Division of Medical Assistance DME Durable Medical Equipment DMV Department of Motor Vehicles DOA Date of Application DOB Date of Birth DOC Department of Corrections DOD Date of Disposition DOT Department of Transportation DRG Diagnosis Related Groupings DSB Division of Services for the Blind DSS (County) Department of Social Services DSS (State) Division of Social Services E&T Employment and Training EA Emergency Assistance EDS Electronic Data Systems EEOC Equal Employment Opportunity Commission EFAP Emergency Food Assistance Program EFCP Expanded Foster Care Program EITC Earned Income Tax Credit EIS Eligibility Information System EOB Explanation of Benefits EOO Economic Opportunity Office EPICS Enterprise Program Integrity Control System

North Carolina Department of Health and Human Services AGED, BLIND, AND DISABLED MEDICAID MANUAL

MA-200

DEFINITIONS

3 REVISED 11/01/08 – CHANGE NO. 24-08 (I.) EPSDT Early and Periodic Screening, Diagnosis and

Treatment (now called HEALTH CHECK) ESC Economic Services Committee ESC Employment Security Commission F&CS Family and Children's Services FC Foster Care FEMA Federal Emergency Management Act FFP Federal Financial Participation FH Foster Home FL-2 Level of Care Designation Form FNS Food and Nutrition Services FPL Federal Poverty Limit FPW Medicaid Family Planning Waiver FRR Financial Resource Report FS Food Stamps FSA Family Service Association FSIS Food Stamp Information System FY Fiscal Year GA General Assistance GS General Statutes HCWD Health Coverage for Workers with Disabilities HH Household HHS U.S. Department of Health and Human Services HIPP Health Insurance Premium Payment HIPAA Health Insurance Portability and Accountability Act HIT Home Infusion Therapy HSF State Foster Home Fund HUD U.S. Department of Housing and Urban Development I&R Information and Referral I-AS IV-E Adoption Subsidy and Foster Care ICCA Individual Child Care Arrangement ICF Intermediate Care Facility ICF-MR Intermediate Care Facility - Mental Retardation IE Individual Eligibility Segment IEVS Income Eligibility Verification System IHE Inadvertent Household Error IMC Income Maintenance Caseworker IMS Income Maintenance Supervisor IMS Income Management System INS Immigration and Naturalization Service (currently known as the Bureau of Citizenship and Immigration Service) IPV Intentional Program Violation IRS Internal Revenue Service ISM In-kind Support and Maintenance ISP Institutionalized Spouse

North Carolina Department of Health and Human Services AGED, BLIND, AND DISABLED MEDICAID MANUAL

MA-200

DEFINITIONS

4 REVISED 11/01/08 – CHANGE NO. 24-08 (I.) IV-D Child Support Enforcement IV-E Title IV-E Foster Care and Adoption Assistance JOBS Job Opportunities and Basic Skills LA Living Arrangement LEAA Law Enforcement Assistance Administration LIEAP Low Income Energy Assistance Program LIS Low Income Subsidy LPR Lawful Permanent Resident LTC Long Term Care LTR Lawful Temporary Resident M-AA Medical Assistance to the Aged M-AB Medical Assistance to the Blind M-AD Medical Assistance to the Disabled M-AF Medical Assistance to Families with Dependent Children M-IC Medicaid for Infants and Children MMIS Medicaid Management Information System M-PW Medicaid for Pregnant Women M-QB-Q Medicaid Qualified Medicare Beneficiary M-QB-B Medicaid Specified Low Income Medicare Beneficiary M-QB-E Medicaid Qualifying Individuals 1(QI1) M-RF Medicaid for Refugees MHSA Medicare Medical Health Savings Account M-SB Medicaid - Special Assistance to the Blind MA Medical Assistance MAABD Medical Assistance - Aged, Blind, Disabled MBR SSA Master Beneficiary Record MCI Master Client Index MFP Money Follows the Person MID Medicaid Identification Number MN Medically Needy MPR Medicaid Program Representative MR Mentally Retarded MRR Medicaid Reimbursement Rate MRRB Monthly Report Retrospective Budgeting MR-2 Level of Care Designation Form for Mentally Retarded MSW Master of Social Work M-WD Medicaid - Working Disabled N/C No Change NA Non-Assistance NADA National Auto Dealer Association NCAC North Carolina Administrative Code NCGC North Carolina General Code NCGS North Carolina General Statutes NCHC North Carolina Health Choice NCXPTR North Carolina Exporter

North Carolina Department of Health and Human Services AGED, BLIND, AND DISABLED MEDICAID MANUAL

MA-200

DEFINITIONS

REVISED 03/01/11 – CHANGE NO. 03-11 (I.) NESE Net Earnings from Self-Employment NPA Non Public Assistance OASDHI Old Age and Survivors, Disability and Health Insurance (now RSDI) OASDI Old Age and Survivors, Disability and Insurance OEO Office of Economic Opportunity OJT On the Job Training PA Public Assistance PACE Program of All Inclusive Care for the Elderly PACE, INC. Plan to Assure College in N.C. PASS Plan to Achieve Self-Support PCP Personal Care Provider PCS Personal Care Services PDN Private Duty Nursing PDP Preferred Drug Plan PE Presumptive Eligibility PIL Poverty Income Level PL Public Law PLA Private Living Arrangement PMH Pregnancy Medical Home PML Patient Monthly Liability PNA Personal Needs Allowance PPA Past-Paid Public Assistance PPT Percentage of Cases Processed within the required time standard PRTF Psychiatric Residential Treatment Facility PW Pregnant Woman QC Quality Control QDWI Qualified Working Disabled Individual (same as M-WD) QI Qualifying Individuals QI1 Qualifying Individuals 1 (same as MQB-E) QMB Qualified Medicare Beneficiaries (same as MQB-Q) QR Quarterly Report R/S Representative's Statement ROD Registrar of Deeds RF Refugee RMDS Report Management and Distribution System (now changed to XPTR or NCXPTR) RR Railroad Retirement RSDI Retirement, Survivors, Disability Insurance S/C SA State/County Special Assistance for Adults SA Special Assistance S-AA Special Assistance for the Aged S-AB Special Assistance for the Blind S-AD Special Assistance for the Disabled SA-IH Special Assistance In Home Demonstration Project SAVE Systematic Alien Verification for Entitlement Programs SBHF State Boarding Home Funds

5

North Carolina Department of Health and Human Services AGED, BLIND, AND DISABLED MEDICAID MANUAL

MA-200

DEFINITIONS

6 REISSUED 03/01/11 – CHANGE NO. 03-11 (I.) S-CD Special Assistance for the Certain Disabled SDX State Data Exchange SFHF State Foster Home Fund SIS Services Information System SLMB Specified Low Income Medicare Beneficiaries (same as M-QB-B) SNF Skilled Nursing Facility SO State Office SOLQ State Online Query SSA Social Security Administration SSI Supplemental Security Income SSN Social Security Number SUA Standard Utility Allowance SUR Services User Record (over utilization) SW Social Worker T/C Telephone call TAD Turn Around Document TANF Temporary Assistance for Needy Families (called WFFA in North Carolina) TBR Transitional Benefit Report TC Transaction Code TFP Thrifty Food Plan TFAP Temporary Food Assistance Program TMA Transitional Medicaid TPL Third Party Liability TPQR Third Party Query Response TPQY Third Party Query TPR Third Party Recovery UA Utility Allowance UI Unemployment Insurance UIB Unemployment Insurance Benefits UMN Unmet Medical Needs UR Utilization Review USDA United States Department of Agriculture VA Veterans Administration VAWA Violence Against Women Act VR Vocational Rehabilitation WBA Weekly Benefit Amount WFFA Work First Family Assistance (Nationally known as TANF) WIC Women, Infants and Children WOTC Work Opportunity Tax credit WP Work Program WR Work Registration XPTR Exporter

North Carolina Department of Health and Human Services AGED, BLIND, AND DISABLED MEDICAID MANUAL

MA-200

DEFINITIONS

7 REVISED 11/01/08 – CHANGE NO. 24-08 II. PROGRAMS

Benefit Diversion --- A cash payment assistance alternative to traditional Work First Family Assistance (WFFA) for families with a temporary, non-recurring situation associated with employment or other sources of financial stability.

Breast and Cervical Cancer Medicaid --- A program of medical assistance for women enrolled and screened for breast and cervical cancer through the Breast and Cervical Cancer Control Program.

Emergency Assistance --- A cash payment program to assist families with children who are in a crisis situation.

Community Alternative Programs (CAP) --- Special Medicaid for individuals placed in the community who are at risk of institutionalization.

MFP --- Money Follows the Person. MFP provides the services and supports necessary to allow Medicaid eligible people, who meet the criteria for enrollment in CAP/Choice, CAP/DA, CAP- MR/DD, or PACE to move out of institutions and back home or into the community.

Energy Assistance --- Cash payments offered to eligible households to help defray the high cost of heating/cooling.

a. CIP --- Assistance with heating or cooling related emergencies.

b. LIEAP (LIHEAP) --- Annual cash payment to low-income households to assist with heating costs.

c. Other Energy Assistance Resources --- Private and/or public moneys available in some counties to assist low-income households with heating or cooling costs (i.e. Project Share, FEMA, etc.).

Expanded Foster Care Program (EFCP)--- for IAS and HSF adolescents ages 18, 19, and 20 will be without regard to the adolescent’s assets or income levels through the month they turn age 21.

Food and Nutrition Services --- A program to assist eligible households with the purchase of food.

Health Coverage for Workers with Disabilities (HCWD) --- A program to allow individuals with disabilities to work and receive income while maintaining Medicaid benefits.

Low Income Subsidy --- A program that provides additional assistance for Medicare beneficiaries with income less than 150% of the federal poverty level for the Medicare Part D program.

Medicaid Family Planning Waiver (FPW)--- A program for men, ages 19 through 60, and women, ages 19 through 55, with income at or below the 185% of the poverty level, to receive family planning services.

Medical Assistance --- (Medicaid) A program to assist eligible aged, disabled, blind, individuals, pregnant women, families and/or children with the cost of medical care.

M-AA --- Medicaid to the Aged. A program of medical assistance for individuals age 65 and over.

North Carolina Department of Health and Human Services AGED, BLIND, AND DISABLED MEDICAID MANUAL

MA-200

DEFINITIONS

8 REISSUED 11/01/08 – CHANGE NO. 24-08 (II.)

M-AB --- Medicaid to the Blind. A program of medical assistance for individuals of any age who meet Social Security's definition of blindness.

M-AD --- Medicaid to the Disabled. A program of medical assistance for individuals under age 65 who meet Social Security's definition of disability.

M-AF --- Medicaid to Families with Dependent Children. A program of medical assistance for children and adults who meet the requirements of eligibility.

a. MAF-D --- Medicaid Family Planning Waiver

b. MAF-W --- Breast and Cervical Cancer Medicaid

M-IC --- Medicaid to Infants and Children. A program for medical assistance for children under the age of 19 whose countable income falls under a specified percentage of the Federal Poverty Limit.

M-PW --- Medicaid for Pregnant Women. A program for medical assistance for pregnant women whose income falls under a specified percentage of the Federal Poverty Limit.

M-QB-B --- Specified Low Income Medicare Beneficiaries. A limited Medicaid program which pays a recipient's Medicare B premiums only.

M-QB-Q --- Qualified Medicare Beneficiaries. A limited Medicaid program that pays a recipient's Medicare premiums, deductibles and copayments only.

M-QB-E --- Qualifying Individual 1 (QI1). A limited Medicaid program which pays a recipient’s Medicare B premiums only. Funding for the program is capped.

M-RF --- Refugee Assistance. A medical assistance program for refugees.

M-SB --- Medicaid for Special Assistance to the Blind. A medical assistance program for recipients of Special Assistance to the Blind money payments.

M-WD --- Qualified Disabled Working Individuals. Individual who is eligible for Medicaid payment of Medicare Part A premiums after automatic entitlement to free Part A ends due to individual's earnings and whose income does not exceed 200% of poverty level. This is the only Medicaid benefit covered by this program.

NCHC --- North Carolina Health Choice for Children. A health insurance program for uninsured children under the age of 19 who do not qualify for Medicaid and have family income under 200% of the Federal Poverty Limit. Funding for this program is capped. This program is known as Children’s Health Insurance Program (CHIP) at the national level.

North Carolina Department of Health and Human Services AGED, BLIND, AND DISABLED MEDICAID MANUAL

MA-200

DEFINITIONS

REVISED 03/01/11 – CHANGE NO. 03-11 (II.) PACE --- Program of All-inclusive Care for the Elderly. A managed care service delivery for the frail community-dwelling elderly, most of whom are dually eligible for Medicare and Medicaid benefits, and all of whom are certified eligible for nursing home placement according to North Carolina standards.

Pregnancy Medical Home (PMH) -- A managed care service that assists pregnant Medicaid recipients with perinatal care (the period immediately before and after birth) thereby ensuring healthy pregnancies and improving birth outcomes. This will be done by modeling the PMH after the enhanced primary care case management (PCCM) program developed by CCNC.

Special Assistance - (SA)

a. Adult Care Home --- Cash payments and medical assistance for eligible aged, disabled and blind individuals residing in a licensed adult care home facility.

b. Certain Disabled --- Cash payment only for individuals in a private living arrangement who meet the state's definition of disability. (This program is not available in all counties.)

c. In-home --- Cash payments and medical assistance for eligible aged, disabled and blind individuals residing in a private living arrangement who are at risk of placement in an adult care home.

Work First Family Assistance --- A cash payment and Medicaid program for families with children who are low income. This program is known as TANF at the national level.

III. DEFINITIONS

Actuarially Sound – A promissory note, annuity, mortgage or loan established to pay off the entire asset value over the actual or expected lifetime of the annuitant/lender is actuarially sound. The annuitant/lender is expected to live long enough to receive an amount that is equal to or greater than the amount originally invested. The total amount of proceeds must be designed to be paid out in equal amounts during the term of the agreement, with no deferral and no balloon payments.

Annuitant – An annuitant is the person who receives the income payments of an annuity policy at maturity date for life or for a specified period. The annuitant may or may not be the same as the owner.

Annuitize – Converting the principle of an annuity into a series of payments.

Annuity - An annuity is a type of trust. An individual pays an entity a lump sum of money in return for the right to receive fixed, periodic payments, either for life or a term of years. This includes the investment portion of a single premium pure endowment life insurance policy.

9

North Carolina Department of Health and Human Services AGED, BLIND, AND DISABLED MEDICAID MANUAL

MA-200

DEFINITIONS

10 REISSUED 03/01/11 – CHANGE NO. 03-11 (III.) Actual Time Report Card --- A report card that shows individual county/DDS average processing time and the percentage processed timely counting actual days to complete applications in a month. The actual processing time excludes no days and does not adjust the 45th/90th day.

Add-on --- Any individual added to an active case.

Adequate Notice --- A notice that must be received before the effective date of the change that informs the a/r of action taken.

Adjusted Payment --- A payment to the recipient to correct an underpayment and/or other upward adjustments that are needed

Adjusted Application Report Card --- A report card that shows the individual county/DDS average processing time and percentage processed timely excluding days allowable by policy to complete applications.

Adult Care Home --- Licensed group care facility.

Affidavit of Support --- This is a statement of a sponsor’s income, resources, and willingness to support an alien. It is filed with the BCIS by a U.S. resident who sponsors an alien seeking admission to the U.S. as a permanent resident.

Alien --- An alien is an individual who lives in the U.S. but is not a citizen.

Appeal --- An appeal is a request of an applicant/recipient or his representative for a review of the action taken on his case. An SSI Medicaid recipient will appeal through SSA. A non-SSI Medicaid recipient will request an appeal through his county income maintenance caseworker. An appeal of the level of care is requested through the North Carolina Division of Medical Assistance.

Applicant --- A person who signs under penalty of perjury a written application for MA or on whose behalf a written application is made and signed by an authorized representative.

Application --- An application for MA signed by the applicant or his authorized representative.

Application Process --- A series of actions leading to a determination of eligibility or ineligibility for MA.

Approved Amount --- In Medicare claims, the portion of the medical charge that Medicare approves as reasonable. Medicare pays 80% of the approved amount.

Approved Level of Care --- The level of care recommended by the patient's attending physician that meets level of care criteria and is approved by the Prior Approval Unit. See FL-2/MR-2.

Assessment --- The procedure for determining the community spouse's share of resources owned by the couple at the time of institutionalization.

Asset – For purposes of transfer of assets, is resources and income.

North Carolina Department of Health and Human Services AGED, BLIND, AND DISABLED MEDICAID MANUAL

MA-200

DEFINITIONS

11 REISSUED 03/01/11 – CHANGE NO. 03-11 (III.) Assignment --- For Medicare, the medical provider's agreement to accept Medicare's approved amount. Medicare pays the provider directly and the provider may charge the patient only the 20% coinsurance. Providers must accept the Medicare assignment if they bill Medicaid for the 20% coinsurance.

Assistance Unit --- The assistance unit (a.u.) consists of the individuals for whom assistance is requested, who are eligible and in the same coverage group and who have the same financially responsible person(s).

Assisted Living --- Group care for a person who cannot remain in his own home and who is placed in a facility licensed by the Department of Health and Human Services as an adult care home.

Authorization Period --- Period for which all factors of eligibility have been established and the recipient is authorized to receive Medicaid.

Authorized Representative --- Any individual who is legally authorized or designated in writing by the applicant/recipient to act on behalf of the applicant/recipient.

Automated Notice --- A notice produced and mailed by EDS to an applicant/recipient based on codes entered by the income maintenance caseworker when action is keyed.

Award Letter --- A statement to an individual from a governmental or private agency indicating benefits for which he/she is eligible.

Base Period --- A designated time for verifying income that is counted in determining the benefit.

Battered Alien --- An immigrant who has been battered or subjected to extreme cruelty by a spouse, parent, or member of the spouse or parent’s family residing in the same household.

Beneficiary of an annuity – The beneficiary is the person who receives any benefit that is paid upon death of the annuitant prior to the maturity date of the annuity.

BENDEX --- Beneficiary Data Exchange System, a computer printout listing the amount of an individual's Social Security benefits.

Benefit Diversion --- Benefit Diversion is a cash payment assistance alternative to traditional Work First Family Assistance (WFFA) for families with a temporary, non-recurring situation associated with employment or other sources of financial stability.

Black Lung --- Payments to a disabled worker, dependents, or survivors resulting from exposure to coal dust.

Boarder --- A person who lives with the a/r and pays a set amount for a room and meals.

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DEFINITIONS

12 REISSUED 03/01/11 – CHANGE NO. 03-11 (III.) Brown Lung Benefits --- Payments made to persons disabled by lung disease resulting from exposure to raw cotton dust.

Budget Unit --- Persons whose income and resources are considered in the determination of eligibility for an individual or family group.

Caretaker Relative --- The natural or adoptive parent or the specified relative living in the household with the child who is eligible for Medicaid and providing the child's day-to-day care and supervision.

Carolina Access --- A program to link Medicaid recipients with a primary care provider who agrees to provide or arrange most of the enrollee's health care services.

Case ID Number --- A unique computer-assigned identification number.

Case Number --- A number assigned to a case by a county department of social services.

Case Record --- A file containing the application and all documents verifying initial and continuing eligibility for members of the assistance unit.

Casehead/Payee --- The person to whom the benefits are written.

Categorically Needy – SSI Recipient -- Medicaid classification for individuals receiving SSI who are automatically eligible for Medicaid. Classification will always be C or Q (if Medicare). The aid program/category is MAD, MAA, SAA, SAD, AAF payment type 5 or HSF.

Categorically Needy – Non SSI Recipient --- Medicaid classification for Work First coverage groups and for Medicaid cases with caretaker relatives and/or children under 21 who meet the categorically needy income and, if applicable, asset requirements. Classification is C or N. Work First cases must be classified C. Individuals age 19 and 20 who are not caretakers of a child and independently living children under 19 who are not otherwise eligible for MIC must be evaluated for MAF-N. Individuals determined eligible under a poverty coverage group must be N (either MIC or MPW). Caretaker relatives and other children under 19 who meet categorically needy requirements are classified C.

Certification period --- The period of time for which assistance is requested and in which all eligibility factors except need and reserve (when applicable) must be met.

Change in Situation --- A change in a recipient's circumstances that may affect eligibility for assistance.

Child Support --- Money or in-kind goods given for a child by a parent for the child's care.

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DEFINITIONS

13 REISSUED 03/01/11 – CHANGE NO. 03-11 (III.) Child Tax Credit (CTC) ---Supplement to the earnings of low income taxpayers with earned income. Must be a parent, step-parent, grandparent, or foster parent with a dependent child. The child tax credit may provide a refund to individuals even if they do not owe any tax. There is no advance payment with CTC.

Children’s Health Insurance Program (CHIP) --- The national title for the Health Choice program. (See North Carolina Health Choice.)

Client --- means any applicant for or recipient of Medicaid, or someone who makes inquiries, is interviewed, or has been otherwise served.

Closing Date --- The last day of the month in which the a/r is eligible for benefits.

Collateral --- Any individual, employee, or person representing an agency, firm, organization, etc., whom the Income Maintenance Caseworker approaches to obtain verification of information provided by the budget unit.

Commissions --- Percentage of money made on sales and given in pay, in addition to salary or wages.

Communal Dining Facility --- A public or nonprofit private establishment, approved by FNS, which prepares or serves meals for elderly persons or for Supplemental Security Income recipients and their spouses.

Community Spouse --- The non-institutionalized spouse of an institutionalized spouse.

Community Spouse Resource Allowance --- An amount of countable resources held by the institutionalized spouse, the community spouse or both which is protected for the use of the community spouse. This amount is not considered available to the institutionalized spouse.

Compensation ---- Something received as payment for an asset. Payment is usually considered to be cash, but other forms of payment include in-kind income, real or personal property, support and maintenance, services, or assumption of a legal debt.

Confidentiality --- Safeguarding client information.

Contested Decision --- A tentative State hearing decision with which a county or the a/r disagrees.

Contiguous Property --- Real property with boundaries that touch the homesite property, disregarding the presence of streets, roads, rivers or streams.

Continuous Eligibility --- Once a child under age 19 has qualified for Medicaid he can receive for up to 12 months regardless of financial changes that affect eligibility.

Contribution --- Donation of cash or in-kind made by an individual to or on behalf of a member of the budget unit.

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DEFINITIONS

14 REISSUED 03/01/11 – CHANGE NO. 03-11 (III.) Cost of Care ---- The amount of money charged to an individual for NF or ICF-MR level of care, a swing bed, or inappropriate level of care bed in a hospital, or waiver services for the Community Alternatives Program (CAP).

County Case Transfer --- The process of referring a case from one county to another based upon the client's new residence. (See County Reassignment)

County Reassignment --- Case action taken when an a/r moves from one county to another.

Court-Ordered Guardianship Fees --- A fee owed to an a/r’s guardian due to a court order and which is deducted from the a/r’s income.

Court-Orders --- Decisions made by judges of courts of competent jurisdiction that specify changes and/or procedures the county DSS's must follow (i.e. Blue v. Craig, child support, custody).

Coverage Group --- The category under which an individual is determined eligible for assistance.

Current Market Value --- The value of an asset if sold on the open market. For real and personal property it is the tax assessed value of the property, unless that value is rebutted and a different value established. Refer to MA-2230, Financial Resources, for instructions on establishing and rebutting the tax value.

Deductible --- An amount for medical expenses that must be paid or incurred by the applicant/recipient or a current budget unit member before Medicaid can be authorized. A deductible results when the countable income of the budget unit members exceeds the established income or maintenance level for the number of persons in the budget unit. (Sometimes called a "spenddown.")

Deductible Balance --- The amount of the deductible remaining to be met on the date Medicaid is authorized and which the applicant/recipient is responsible to pay.

Deduction --- Mandatory and allowable work related expense subtracted from gross earned income for members of the budget unit.

Deemed --- The process of considering income and reserve of persons in the household, or sponsors of lawfully admitted aliens as available to the a/r.

Demonstrated Hardship – The a/r, spouse or personal representative proves through the greater weight of evidence that a denial of institutional services due to excess home equity value will cause the a/r a hardship.

Denial --- Rejection of benefits of the applicant.

Dependent --- An individual who is financially dependent upon another for his well being as defined by financial responsibility regulations for the program.

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15 REISSUED 03/01/11 – CHANGE NO. 03-11 (III.) Deregistration --- The process by which an individual is removed from work registrant status.

Destitute Households ---- A migrant or seasonal farm worker household whose terminated income was received prior to the date of application and/or no more than $25 will be received from a new source by the 10th day of the month of application. (Applicable to Food Stamp program only.)

Determination of Eligibility --- The process of verifying eligibility factors for applicants/recipients to arrive at a decision on eligibility or ineligibility for programs based on the North Carolina Administrative Code, North Carolina General Statutes, and Federal Regulations.

Diagnosis Related Groupings --- Medicare and Medicaid reimburses general hospitals based on DRG's, a set fee based on the hospital's classification and the patient's diagnosis. The fee paid may be greater or less than the actual charge for the specific procedure provided. The hospital accepts the DRG fee as payment in full. The patient may not be billed if the fee paid is less than the actual charge. Conversely, the patient may not be credited for any excess if the DRG fee paid is greater than the actual charge. He will be responsible only for the Medicare Part A or Medicaid deductible.

Disability --- As defined by the Social Security Administration (SSA), a physical or mental impairment of such severity that it prevents the applicant from engaging in substantial gainful activity (or for a child under 18, an impairment of comparable severity) for at least a year or is expected to result in death. Note: substantial gainful activity is not a consideration for determining disability in HCWD cases.

Disability Determination Services --- The section of the North Carolina Division of Vocational Rehabilitation (VR) that is responsible for making determination of disability for RSDI, SSI, and Medicaid.

Disabled Adult Child --- An individual who is blind or permanently and totally disabled who is unable to become self-supporting after age 18.

Disqualified Individual --- An individual removed from Food Stamps due to an Intentional Program Violation, or for failure or refusal to comply with all program requirements.

Disregard of Earned Income --- Exemption of a portion of earned income for applicants/recipients.

Disregard of Income --- The procedure for exempting certain portions of income when determining benefits.

Division of Medical Assistance --- A division of the North Carolina Department of Health and Human Services responsible for the administration of the Medicaid program.

Division of Services for the Blind --- A division of the North Carolina Department of Health and Human Services responsible for providing financial and medical assistance and services for the blind.

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16 REISSUED 03/01/11 – CHANGE NO. 03-11 (III.) Division of Social Services --- A division of the North Carolina Department of Health and Human Services responsible for providing financial assistance and services for families with children and aged and disabled individuals.

Documentation --- Record data substantiating all points of eligibility.

Earned Income Tax Credit --- Is a supplement to the earnings of the working poor. An eligible individual can choose to receive the credit in advance payments added to his paycheck or in a lump sum when he files his income tax return.

Effective Date --- The first day of the authorization period for MA.

Eligibility --- The status of an individual qualifying for MA.

Emancipated Minors --- Children who are no longer legally dependent upon their parents/guardians, due to marriage, etc.

Emergency Services Medicaid --- Eligibility for Medicaid by non-qualified aliens is limited to receipt of Medicaid on the days an emergency existed. An emergency is defined as labor and delivery or treatment after the sudden onset of a medical condition manifesting itself by acute systems of sufficient severity, including severe pain, such that absence of immediate medical attention could reasonably be expected to result in placing the patient’s health in serious jeopardy, or serious impairment to bodily function, or serious dysfunction of any bodily organ or part.

Enumeration --- The process of obtaining a Social Security Account Number.

Equity - The equity of real or personal property is the current market value (see definition above) less any encumbrances (mortgages, liens, or judgments) on the property.

Essential Person --- A person who gives essential service to the a/r and, if in need, is eligible to be included in the assistance unit.

Essential Spouse --- The spouse included in an AABD money payment in 12/73 who continues to be the spouse of and live with the individual who has continued to receive MA since 12/73 without termination.

Estate Recovery --- A claim filed against the estate of a deceased Medicaid recipient when Medicaid has paid for certain medical services. The claim is filed to recover Medicaid dollars paid on behalf of the individual.

Exemption --- Income that is subtracted from an AABD-MA applicant's/recipient's total monthly income, whether earned or unearned.

Ex Parte --- A determination of Medicaid eligibility from an existing record (such as from the SDX, county record, etc.)

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DEFINITIONS

17 REISSUED 03/01/11 – CHANGE NO. 03-11 (III.) Expedited Services --- A procedure whereby the agency provides certain Food Stamp households an opportunity to receive benefits within a shortened time frame.

Fair Market Value --- For real or personal property, the tax value of the resource at the time of the transfer as verified by the county tax office, and for liquid assets, the current market value of the resource at the time of the transfer as defined in the Financial Resources Section.

Family Allowance --- The amount of income protected from an institutionalized spouse's income for a dependent family member.

Father, Alleged --- The man who is said, without proof, to be the father of the child when the courts have not established paternity.

Father, Legal --- (1) The man who is married to the mother at the time of the child's birth; or (2) A man who has been determined by the courts to be the father; or (3) A man who has legally adopted the child; or (4) A man who has signed affidavits legitimating the child.

Father, Natural --- The biological father of the child.

Father, Putative --- Same as Alleged Father.

Final Decision --- A decision by the State hearings office, after all non-judicial appeal rights have been exhausted.

Financially Responsible Person --- A parent or spouse whose income and resources are considered available to the Medicaid a/r as long as the a/r and the parent or spouse live together in the same household. Applies to PLA living arrangement only. (Same as budget unit.) For aliens admitted due to a sponsor, the sponsor and/or the sponsor’s spouse are financially responsible for the alien by deeming their income to the alien a/r following rules in MA-2262, Sponsor Deeming. They are not considered part of the budget unit and do not need to live with the alien.

FL-2 --- Long-Term Services prior approval form which gives a summary of the patient's medical requirements and which reflects the attending physician's recommendation for the level of care needed in an institutional setting. An approved FL-2 is required for any Medicaid recipient in a skilled nursing facility (SNF) or an intermediate care facility (ICF).

Forgery --- Signing someone else's name without proper authorization.

Fraud --- A criminal act in which an a/r or authorized representative makes a false statement and/or withholds information willfully, knowingly, and with deceitful intent and, as a result, obtains or attempts to obtain assistance for which he is not eligible.

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DEFINITIONS

18 REISSUED 03/01/11 – CHANGE NO. 03-11 (III) Focused Risk Management Program (FORM) – (formerly Medication Therapy Management) Medicaid recipients participating in FORM may have their prescription overridden at the discretion of the pharmacist. The pharmacists coordinates, integrates and communicates medication regimen discussions with the patients primary care provider and upon consensus, translates the information to the recipient.

Greater Weight of the Evidence – Refers to the quality and convincing force of the evidence rather than to the quantity of the evidence

Guardian --- A person appointed by a court to be legally in charge of the affairs of a minor, or of someone incapable of taking care of his own needs.

Hearing --- A review requested by an a/r to establish whether an adverse action taken by the county department of social services was correct. (See appeal.)

Heir Property --- Ownership of property passed by will or intestate succession.

Homeless --- An individual who lacks a permanent or fixed residence.

Homesite --- Principal place of residence owned by an a/r or a budget unit member.

Identification Card --- A card issued yearly which identifies a person who was authorized for Medicaid when the card was issued. The card does not serve as verification of current eligibility status.

Illegal Alien --- Aliens who entered the U.S. without knowledge of BCIS or were admitted for a limited period of time and did not leave the U.S. when the period of time expired. These aliens may be known or unknown in BCIS but are not in a satisfactory status with BCIS.

Income --- Cash or in-kind resources received for labor, services, government or private benefits, or any money available to members of the budget unit for their maintenance.

Income, Earned --- Money received as a result of employment.

Income, Gross --- Total income before allowable deductions.

Income, Net --- Income after all allowable deductions.

Income, Unearned --- Money received from any source other than employment.

Income Level --- See Maintenance Allowance.

Income Maintenance Caseworker --- Person employed by the county department of social services to determine eligibility for income maintenance programs.

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19 REISSUED 03/01/11 – CHANGE NO. 03-11 (III.) Incur --- Become liable for, regardless of whether the expense is paid or expected to be paid by insurance, including Medicare, or some other source.

Incurred Medical Expense --- A charge for a medical service provided to an individual regardless of whether it is paid or unpaid. It may be applied to the Medicaid deductible if it will not be reimbursed.

In-Home Health Services and Supplies---Medically necessary services provided to an applicant/recipient (a/r) by a Medicaid certified provider can be sanctioned due to a transfer of assets. These services include the following:

a. Durable Medical Equipment (DME) and related medical supplies such as wheelchairs, walkers, canes, hospital beds, oxygen and oxygen equipment, needed to maintain or improve a recipient’s medical, physical, or functional level.

b. Home Health Services covers home health aide services, skilled nursing, physical therapy, speech pathology and audiology, and occupational therapy provided by a Medicaid certified home health agency to help restore, rehabilitate or maintain a recipient in the home.

c. Home Health Supplies include items such as adult diapers, disposable bed pads, catheter and ostomy supplies provided by a Home Health or Private Duty Nursing (PDN) agency. PDN services are not provided to individuals in an Adult Care Home (ACH).

d. Home Infusion Therapy (HIT) covers self-administered therapies such as nutrition therapy (tube feeding), drug therapy including chemotherapy for cancer treatments, antibiotic therapy and pain management therapy.

e. Personal Care Services (PCS) are personal care activities such as bathing, toileting, monitoring vital signs, housekeeping and home management tasks essential for maintaining the recipient’s health performed by an in-home aide in a private residence.

PCS services provided to individuals in an ACH are not subject to this policy. Refer to MA-2240, Transfer of Assets, for an explanation of services.

In-kind Income --- Non-monetary assistance such as food, shelter or something the individual can use or convert to obtain food, or shelter.

Inmate of a Public Institution --- A person who is living in a public institution.

Inquiry --- A request for information regarding assistance or other services.

Institutional Living Arrangement – Institution or establishment that provides food, shelter and some treatment to 4 or more persons who are not related to the owner. This includes nursing facilities, group homes, orphanages, adult care homes, and residential treatment facilities.

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DEFINITIONS

20 REISSUED 03/01/11 – CHANGE NO. 03-11 (III.) Institutionalized – Long Term Care Budgeting/Community Spouse Resource Allowance and Continuous Period of Institutionalization. This is 30 consecutive days in a medical facility or combination of medical facilities. The facilities are nursing facility, intermediate care facility-mental retardation, (ICF-MR) swing bed, inappropriate level of care in a hospital, or hospital acute level, and psychiatric residential treatment facility (PRTF).

Institutional Services - These services include services provided in a nursing facility (NF), intermediate care facility for the mentally retarded (ICF-MR), swing bed or inappropriate level of care bed, services provided through the Community Alternatives Program (CAP), or Program of All- Inclusive Care for the Elderly (PACE). These services can be sanctioned due to a transfer of assets. These services do not include acute hospital care regardless of length of stay.

Institutionalized Spouse - An individual who is in SNF, ICF-MR, swing bed or inappropriate level of care bed, state mental hospital, or a general hospital after 30 days, or is approved for CAP/DA or CAP/MR, or PACE, and is married to a spouse who is not institutionalized.

Institutionalized for Transfer of Assets – As defined for a transfer of assets review, institutionalized is an individual receiving institutional services in a nursing facility (NF), intermediate care facility for the mentally retarded (ICF-MR), swing bed, inappropriate level of care bed in a hospital, services provided through CAP, or services provided through PACE. This is different from the definition of institutionalized for long term care budgeting or institutional living arrangement when determining state/county residency.

Intake --- An initial interview.

Intermediate Care Facility - Mental Retardation Section (ICF-MR) --- An ICF for the mentally retarded that is affiliated with the State's retardation centers or mental hospitals.

Investigation --- A thorough examination of all eligibility factors.

Irrevocable Trust --- A contract in which the terms cannot be altered.

Job Bonus --- A one time 100% exclusion of earned income for 3 consecutive months for each parent/specified relative included in the assistance unit who becomes employed. Job Bonus is applicable ONLY to MAF-C and Work First cases.

Katie Beckett --- (CAP for Children) Medicaid Community Alternatives Program to allow disabled children who are at risk for institutionalization to receive medical care at home. Term used by other states. Katie Beckett is referred to as CAP-C in North Carolina.

Lawful Permanent Resident --- An alien who is legally admitted to the U.S. by the BCIS to live and work on a permanent basis.

Legal Parent --- Natural or adoptive parent after the final order of adoption is issued.

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21 REISSUED 03/01/11 – CHANGE NO. 03-11 (III.) Legal Representative --- A person acting for and legally authorized to execute a contract for the a/r, such as but not limited to a legal guardian, parent of a minor child, holder of power of attorney, fiduciary (agent), conservator or any trustee managing the a/r’s resources. Legal authorization requires a separate legal document except for parents of minor children.

Legal Temporary Residents --- These are aliens who have applied for legalization and been granted lawful temporary resident status (LTR) and eventually granted lawful permanent residence.

Live-in Attendant --- An individual who resides in a household solely for the purpose of providing medical, housekeeping or childcare services.

Loans --- Money given with the intention of repayment.

Local Conference --- A conference held by the county DSS with a recipient regarding the proposed action on his Food Stamp case.

Local Hearing --- A hearing held by the county department of social services with the recipient following a written notice to the recipient regarding a change in his MA. Additional information may be presented by the recipient who may affect a decision in the case.

Long Term Care (LTC) Budgeting --- Budgeting for individuals who are in an institutional setting rather than in a private home setting. Spousal and parental financial responsibility does not apply in this type of budgeting. The cost of care (room and board) is considered a medical expense and is usually covered along with other medical expenses.

Long Term Care (LTC) Facility --- A skilled nursing facility (SNF), intermediate care facility for the mentally retarded (ICF-MR), state mental hospital, or general hospital after 30 continuous days.

Long Term Care (LTC) Living Arrangement --- Residence in a "nursing home setting" such as skilled nursing facility (SNF), intermediate mentally retarded (ICF-MR), or hospital swing bed/inappropriate level of care bed.

Long Term Care Ombudsman --- An advocacy program mandated by the Older Americans Act and North Carolina General Statutes. LTC Ombudsman assist LTC patients and their families with problems and questions related to LTC.

Lookback Date - The earliest date a transfer can occur and be evaluated for a transfer of assets for less than fair market value. The lookback date varies depending on when an individual applies for Medicaid, is admitted to a NF or ICF/MR or requests CAP waiver services. Sanctions can be determined for transfers that take place on or after the lookback date.

Low Income Subsidy (LIS) --- A program that provides additional assistance for Medicare beneficiaries with income less than 150% of the federal poverty level for the Medicare Part D program.

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REVISED 03/01/11 – CHANGE NO. 03-11 (III.) Lump Sum Payment --- Money received with no anticipated recurrence.

Maintenance Allowance --- Amount an individual or family group is allowed for basic needs or maintenance.

Manual Notices --- In certain situations the IMC must complete and mail the appropriate notice informing the a/r of changes or adverse actions to be taken in his case.

Mass Revisions (Changes) --- Certain changes that are initiated by the State or Federal government that may affect the entire caseload or significant portions of the caseload.

Means Tested Program --- An assistance program in which an applicant's financial circumstances are considered.

Medicaid Certified --- Enrolled in the North Carolina Medicaid program.

Medicaid Couple --- An MAABD/MQB Medicaid a/r who is married and living with a spouse who is applying for or receiving MAABD/MQB Medicaid.

Medicaid Family Planning Waiver (FPW) --- A program for men age 19 through 60 and women age 19 through 55, with income at or below 185% of the federal poverty level, to receive family planning services.

Medicaid Individual --- A Medicaid a/r who is single or who is married to a WFFA or SSI Recipient.

Medicaid Ineligible Spouse --- An individual not receiving MAABD/MQB Medicaid who is married to and living with a spouse who receives MAABD/MQB Medicaid and who is not an WFFA or SSI recipient.

Medicaid Reimbursement Rate --- The rate at which a given facility is reimbursed for a Medicaid recipient in the approved level of care.

Medical Home -- A primary health care doctor’s office.

Medical Institution --- An institution that provides medical care, including nursing and convalescent care, such as a hospital.

Medicare --- A program of health insurance for aged and disabled individuals who meet the program's eligibility requirements. Title XVIII of the Social Security Act.

Medicare Medical Health Savings Account (Medicare Advantage) (MHSA) -- Yearly Medicare deposits into an interest-bearing account to help the plan member cover their health care costs until the deductible is met. The accounts are linked to high deductible health insurance polices. These plan account funds are a countable resource for Medicaid purposes.

Medicare Part D --- A prescription drug program through Medicare that provides all Medicare beneficiaries with prescription drug assistance. The Low Income Subsidy is a part of this program.

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23 REISSUED 03/01/11 – CHANGE NO. 03-11 (III.) Migrant Farm Worker --- A person who moves with the migrant stream in order to follow seasonal farm work employment, and does not return to his permanent home each night.

Military Allotments --- Benefits received by dependents of military personnel.

Minimum Medicaid Reimbursement Rate --- The lowest rate at which any facility in the state is reimbursed for a Medicaid patient in the approved level of care.

Minor Mother --- A mother below a certain age as defined by a specific program.

Misrepresentation --- An intentional or unintentional statement giving incomplete, false, or misleading information.

Multiple Household --- A household made up of more than one family unit. This does not include room and board situations, as persons in such living arrangements are considered separate households.

Name --- The name entered in EIS through the Individual ID assignment process or the Name Change (NC) screen. Matches Social Security Records (such as SDX, BENDEX, SOLQ, TPQ, Social Security Card, or Medicare Card.)

Needs Standard --- The amount of money the State determines essential to meet minimal standard of living for a family of a specified size.

Needy Spouse --- The spouse of the a/r whose needs and income are considered in the budget.

Net Profit --- The income received from self-employment, farming, roomers, boarders, or small business, minus allowable expenses.

Newborn Coverage --- Automatic Medicaid coverage for newborns based solely on mother's eligibility status.

Non-assistance Household --- A Food Stamp household in which all family members are not recipients of WFFA, SSI, or a combination of the two.

Non-cooperation --- Failure of a budget unit member to comply with program requirements.

Non-immigrant Aliens (temporary residents) --- Aliens who are not permanently residing in the U.S. These aliens are lawfully admitted but only for a specified period of time, such as foreign students, and are in a satisfactory status with BCIS. These aliens are ineligible for full Medicaid.

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DEFINITIONS

REVISED 03/01/11 – CHANGE NO. 03-11 (III.) Non-qualified Alien --- An alien who does not meet the alien requirements to receive full Medicaid coverage. Non-qualified aliens potentially are eligible for emergency services only. Non-qualified aliens include illegal aliens, non-immigrants legally admitted to the U.S. but only for a temporary or specified period of time, and/or aliens admitted legally to the U.S. but who do not fall into one of the specified qualified alien categories.

North Carolina Health Choice for Children (NCHC)--- A health insurance program for uninsured children under the age of 19 who do not qualify for Medicaid and have family income under 200% of the Federal Poverty Limit. Funding for this program is capped. This program is known as Children’s Health Insurance Program (CHIP) at the national level.

Nursing Facility --- A nursing facility is a licensed skilled nursing facility (SNF) or intermediate care facility (ICF-MR).

Old Bills --- Outstanding medical bills that were incurred prior to the current certification period that have not been considered in establishing previous authorization.

Overissuance/Overpayment --- Benefits that are in excess of the amount for which the recipient was eligible.

Overstated PML --- Recipient paid too much toward cost of care due to PML being calculated incorrectly.

Partial Payment --- Assistance paid for a portion of the month. (N/A to Medicaid.)

Pass Along --- The disregard of Social Security benefits when determining eligibility for Medical Assistance.

Patient Monthly Liability (PML) --- The portion of his cost of care that a patient in long-term care is expected to pay.

Payee --- The person in whose name the assistance is made.

Payment month --- The month for which a client receives payment. (N/A to Medicaid.)

Payment Schedule --- A list mailed to the county department by the central office showing checks that will be mailed the subsequent month. (N/A to Medicaid.)

Penalty Period --- The period of time in which an a/r could be ineligible for Medicaid payment of nursing home cost of care, CAP, or in-home health services and supplies due to a transfer of resources. The penalty period is also referred to as a sanction period.

Perinatal---The period immediately before and after birth.

Perjury --- The voluntary violation of an oath or vow by swearing to what is untrue or by omission to do what was promised under oath. A signed application is a signed oath.

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DEFINITIONS

25 REISSUED 03/01/11 – CHANGE NO. 03-11 (III.) Personal Representative --- A substitute payee appointed by the court when the specified relative payee is unwilling or unable to manage the assistance payment in the best interest of the children.

Plan to Achieve Self-Support (PASS) --- The Social Security Act authorizes the exclusion of income and resources of an individual who has a disability or is blind when the individual needs such income and resources to fulfill an approved Plan to Achieve Self-Support (PASS).

Poverty Level --- A Federally established income guideline used to define persons who are economically disadvantaged.

Presumptive Disability or Blindness --- Conditions under which SSI presumes that disability or blindness requirements are met and makes payment for a period of up to six months. If eligibility is not established for full benefits it is not required that repayment of benefits be made.

Presumptive Eligibility --- A determination of limited Medicaid eligibility for pregnant women, completed by qualified medical providers enrolled with and approved by the Division of Medical Assistance.

Primary Heating Source --- The source of heat used most by the household. (N/A to Medicaid.)

Private Disability or Unemployment Benefits --- Includes benefits paid by private insurance plans for persons incapacitated/unemployed.

Private Living Arrangement (PLA) Budgeting --- Evaluation of eligibility for medical charges only when an individual lives in his own home or an adult care home, and spousal and parental financial responsibility applies.

Private Rate --- The rate charged by a facility for a patient who is paying his own cost of care.

Processing Deadline --- The last date in the month the county can take appropriate action on a case.

Program of All-Inclusive Care for the Elderly (PACE) --- A program of all-inclusive care for the elderly. Managed care service delivery for the frail community-dwelling elderly, most of whom are dually eligible for Medicare and Medicaid benefits, and all of whom are certified eligible for nursing home placement according to North Carolina standards.

Program Transfer --- The process of transferring from one category of assistance to another.

Property Tax Value --- The latest tax value of property as ascertained according to Subchapter II of Chapter 105 of the N.C. General Statutes.

Prorated Benefits --- Benefits issued from the date of application. (N/A to Medicaid.)

Prospective Budgeting --- The best estimate of income for a specified period.

North Carolina Department of Health and Human Services AGED, BLIND, AND DISABLED MEDICAID MANUAL

MA-200

DEFINITIONS

26 REISSUED 03/01/11 – CHANGE NO. 03-11 (III.) Protective Payee --- A substitute payee appointed when the payee mismanages her money or fails to comply with program regulations.

Prouty (Age 72) Benefits --- Special benefits paid by SSA to persons age 72 or over who have not worked under the Social Security System; payments are minimal.

Psychiatric Residential Treatment Facility (PRTF) --- A facility that provides treatment for children with mental illness or substance abuse/dependency who require services in a non-acute inpatient setting. The child must require supervision and specialized interventions on a 24-hour basis to attain a level of functioning that allows subsequent treatment in a less restrictive setting.

Public Assistance Households --- A Food and Nutrition Services household in which all members receive or are determined eligible to receive SSI, WFFA, or a combination of the two.

Public Charge --- An alien who has become (for deportation purposes) or who is likely to become (for admission/adjustment purposes) solely dependent on government assistance. Government assistance includes Work First, SSI, and Medicaid for Long Term Care only.

Public Institution --- An institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control.

Public Law --- A generic name for statutes passed by Congress.

Qualified Alien --- An alien who meets the alien requirements to receive full Medicaid coverage. Qualified aliens potentially are eligible for full Medicaid just like U.S. citizens.

Quality Control (QC) --- A management tool used to determine the accuracy of eligibility and evaluation of needed corrective action.

Quarterly Report --- A form issued quarterly to specified recipients for reporting all income, assets, and other eligibility factors as a requirement for continued benefits.

Reapplication --- A subsequent application when a case has been terminated or suspended.

Rebuttal – The process by which an a/r, the a/r’s spouse or representative proves through a greater weight of evidence factors that eliminate or decrease a sanction period.

Recertification --- A review of all factors of eligibility.

Recipient --- An eligible person whose needs are included in the assistance unit.

Recoupment --- Action to recover overpayments/overissuances made to recipients.

Reenrollment/Redetermination of Eligibility --- A complete review of all eligibility factors.

North Carolina Department of Health and Human Services AGED, BLIND, AND DISABLED MEDICAID MANUAL

MA-200

DEFINITIONS

27 REISSUED 03/01/11 – CHANGE NO. 03-11 (III.) Registrant --- An a/r who is required to register with the Employment Security Commission according to program regulations.

Registrant Pool --- The entire group of individuals who are registered with ESC for manpower services.

Regular Employment --- Employment, either full-time or part-time, on a permanent or temporary basis.

Regular Run Register --- A program specific listing mailed to the county indicating client benefits.

Reinstatement --- The reopening of a case without the necessity of a signed application.

Remainder Beneficiary - The person(s) entitled to an annuity's principal, possibly including income that has been accumulated and added to the principal, after the death of the annuitant.

Remainder Interest --- Interest in property over and above life estate holder's share.

Renter --- An individual who pays for separate living quarters.

Replacement of Benefits --- Duplicate benefits issued by the county.

Representative---"Representative" means a person who is acting on behalf of the client.

Reserve --- Cash or its equivalent (liquid assets) and/or real or personal property (non-liquid assets) that are currently available to members of the budget unit.

Residence --- Requirement that a/r’s be living in North Carolina voluntarily with the intent to remain in the state.

Restored Benefits --- Benefits paid to recipients who did not receive them due to an administrative error or change in regulations.

Resulting Trust --- A verbal or written agreement between two or more parties specifying the ownership of an asset.

Retirement, Survivors, Disability Insurance (RSDI) --- A program administered under Title II of the Social Security Act through the Social Security Administration which pays benefits to persons who have contributed enough quarters to the Social Security System, or who are the dependents of one who has contributed to the system, when they are aged or retired, are a surviving spouse or dependent child, or are disabled. NOTE: An individual receiving RSDI as a retired person is not eligible under M-AD, unless he is actually receiving disability and switches to early retirement benefits at age 62.

Retroactive Period --- The period of 1, 2, or 3 months immediately prior to the month of the Medicaid or WFFA application and in which there is a medical need. (No retro coverage for MQB- Q.) For SSI Medicaid the retro period is 1,2, or 3 months immediately prior to the date of the SSI application.

North Carolina Department of Health and Human Services AGED, BLIND, AND DISABLED MEDICAID MANUAL

MA-200

DEFINITIONS

28 REISSUED 03/01/11 – CHANGE NO. 03-11 (III.) Retrospective Budgeting --- Computing income for the benefit month based on actual income in a previous month.

Revocable Trust --- A contract in which terms can be altered.

Right of Recovery --- The responsibility of an individual, institution, corporation, or public or private agency to pay for all or part of medical costs of an a/r.

Roomer --- A person who lives with the a/r and pays a set amount for a room.

SSI Standard of Disability --- A physical or mental impairment which prevents an individual from engaging in any substantial gainful activity (or for a child under 18, an impairment of comparable severity) and which has lasted or is expected to last for at least 12 months or is expected to result in death.

Sanction Period --- The period of time in which an a/r is ineligible for Medicaid payment of institutional services and in-home health services and supplies. In order to sanction in-home health services, the sanction period must have begun during a period the individual received institutional services and continues when the individual goes to private living arrangement. The sanction period is also referred to as a penalty period.

Seasonal Employment --- Employment that is engaged in for a portion of year, at a predictable time each year. The employment may cover a few weeks or several months.

Self-Employment --- Net income of the person from a business enterprise or trade controlled by oneself, i.e., produce sales, farm rental, farming, craft sales, baby-sitting in one's own home.

Self-Supporting --- Maintaining one's self without financial assistance from others.

Skilled Nursing Facility (SNF) --- A long-term care facility which provides twenty-four hour skilled nursing care with a RN or LPN on duty at all times.

Social Security Administration (SSA) --- The agency of the federal government that issues regulations for the RSDI and SSI programs, as well as Medicare and Medicaid, under the Social Security Act.

Specialty Hospitals --- Hospitals providing designated special services (i.e. North Carolina Cancer Institute at Lumberton).

Specified Person --- An individual who (1) is age 60 or over, (2) receives SSI benefits under Title XVI of the Social Security Act or disability or blindness payments under Titles I, II, XIV, XVI of the Social Security Act (such persons include those who have been certified but whose initial payments have not yet been received, or whose checks are entirely recouped to repay a prior overpayment), (3) receives a VA disability payment for a 100% service connected disability, or (4) is a disabled surviving spouse or child of a Veteran.

North Carolina Department of Health and Human Services AGED, BLIND, AND DISABLED MEDICAID MANUAL

MA-200

DEFINITIONS

29 REISSUED 03/01/11 – CHANGE NO. 03-11 (III.) Specified Relative --- A relative who provides care and supervision of a child with whom the child lives.

Sponsor --- A person who signed an Affidavit of Support on behalf of an alien as a condition of the alien’s entry or admission to the U.S. An alien may have more than one sponsor. This does not apply to organizations and institutions, such as churches or service clubs.

Sponsored Alien --- An alien admitted lawfully for permanent residence sponsored by an individual who has signed an Affidavit of Support. Spouse --- An individual who is married to another person, or for Food Stamp purposes, an individual who is holding himself/herself forth to the community as a husband or wife.

Standard Items --- Basic needs allowances used to determine Medicaid classification, measure contributions, establish income from roomers and boarders.

Standard Utility Allowance --- A fixed FS deduction for utilities that the household, if eligible, may choose to use rather than actual utility bills.

State/County Special Assistance for Adults (SC/SA) --- A program of financial and medical assistance for aged and disabled individuals with special needs, such as adult care home placement.

State Data Exchange (SDX) --- A computer file listing the amount of an individual's Supplemental Security Income benefits and which also reflects Social Security amounts for individuals who receive both SSI and Social Security. This file is available as an on-line inquiry.

State Foster Home Funds (SFHF) --- A program of financial assistance for needy children who are placed in foster homes by county departments of social services in accordance with rules and regulations of the Social Services Commission and who are not eligible for IV-E FC.

State Online Query (SOLQ) --- A method of verifying Title II (RSDI) and Title XVI (SSI) benefits for applicants and recipients of Medicaid, Food Stamps, WFFA, etc. When a request is keyed, it is immediately transmitted via a telephone line to the Social Security Administration (SSA), and the response is returned immediately.

Stepparent -- The person who has married a child's natural parent and is not the legal parent of the child.

Straggler Register --- A listing of checks and Medicaid cards issued by the central office for new cases or for cases updated after the regular run cutoff date.

Subsidized Housing --- A Federal subsidy to assist with shelter and utility expenses.

Substantial Gainful Activity --- For disability purposes, gross earnings equal to or exceeding an amount set by Social Security.

North Carolina Department of Health and Human Services AGED, BLIND, AND DISABLED MEDICAID MANUAL

MA-200

DEFINITIONS

30 REISSUED 03/01/11 – CHANGE NO. 03-11 (III.) Substantiate --- Verification of information alleged by the applicant/ recipient/representative.

Supplemental Payments/Issuance --- An additional payment/issuance due to increased needs of the budget unit after the regular payment has been authorized.

Supplemental Security Income (SSI) --- A Federal assistance program administered by the Social Security Administration for aged, blind, and disabled persons under Title XVI of the Social Security Act to guarantee a certain level of income. SSI recipients have contributed nothing or not enough to the Social Security System to be able to receive benefits on their own accounts. Support Payments --- Money paid by an absent parent.

Suspected Fraud --- Basis for belief that an intentional misrepresentation may have occurred.

Tax Value --- The latest tax value of property assessed by the county tax office.

TANF (Temporary Assistance for Needy Families)--- The federal block grant that funds the Work First Family Assistance (WFFA) program.

Tenancy-in-Common --- Ownership of an undivided share of property with two or more owners who were not married to each other at the time the property was gained.

Tenancy by Entirety --- Property owned by a married couple with the rights of survivorship.

Tentative Decision --- A preliminary decision.

Terminated Case --- When assistance has been previously terminated.

Termination --- The ending of specific benefits.

Third Party Liability --- See Right of Recovery.

Third Party Recovery --- Recovery of all or part of a recipient's medical cost from a responsible source such as private insurance.

Thrifty Food Plan --- A USDA determined cost of diet for persons of different ages upon which Food and Nutrition services are determined.

Time Standard --- The requirement to process an action within a specified time.

Timely Notice --- A written notice to inform the recipient of intended action.

Tips --- Gratuities or sums of money in excess of $20 per month given voluntarily for services rendered.

North Carolina Department of Health and Human Services AGED, BLIND, AND DISABLED MEDICAID MANUAL

MA-200

DEFINITIONS

31 REISSUED 03/01/11 – CHANGE NO. 03-11 (III.)

Trade Readjustment Benefits --- Benefits received as compensation for loss of employment because of foreign imports, when the person is eligible also for unemployment benefits. Benefits are payable through the Employment Security Commission.

Trafficking Victim --- An alien who has been forced into the international sex trade, prostitution, slavery and forced labor through coercion, threats of physical violence, psychological abuse, torture and imprisonment.

Transfer - To change ownership or title from one person(s) to another. A transfer also occurs when an individual takes action to waive or renounce assets or an inheritance to which he is entitled or when an individual takes any action that eliminates his ownership or reduces his control of a asset. For example, changing fee simple property to tenancy-in-common property or adding an additional owner to a savings account is considered a transfer.

Transfer Date for Real Property or Interest in Real Property - The date of transfer for real property is the day the deed is signed by the grantor, delivered, and accepted by the grantee. Unless fraud is suspected, it is presumed this is the date recorded on the front of the deed. The deed does not have to be notarized or registered in order to be a valid title transfer. However, a deed of gift must be registered within 2 years to remain valid.

Transfer Month --- The calendar month in which resources were legally transferred.

Transfer of Assets --- Changing of ownership.

Transitional Benefit Report (TBR) --- The form a family on 12 month Transitional Medicaid is required to complete in order to continue to receive Transitional Medicaid.

Transitional Medicaid ---

a. Four Months Transitional Medicaid --- The up to 4-month period of time that a family may receive Medicaid when they have been determined ineligible for Work First or MAF-C because of new or increased child/spousal support which is collected by IV-D or received by a member of the family and forwarded to IV-D.

b. Twelve Months Transitional Medicaid --- The up to 12-month period of time that a family may receive Medicaid when they have been determined ineligible for Work First or MAF-C because of new or increased earned income.

Uncompensated Value - The difference between the market value less encumbrances (the equity) of the asset at the time of the transfer and any payment or compensation received. The uncompensated value is the amount upon which the sanction is based.

North Carolina Department of Health and Human Services AGED, BLIND, AND DISABLED MEDICAID MANUAL

MA-200

DEFINITIONS

32 REISSUED 03/01/11 – CHANGE NO. 03-11 (III.) Underissuance --- The amount of food stamps issued to a household that are less than the amount it was eligible to receive.

Underpayment --- A payment that is less than the recipient is eligible to receive in WFFA.

Understated PML --- Recipient paid too little PML toward cost of care and/or received unmet medical needs allowance to which he was not entitled.

Undue Hardship – The application of the sanction period would deprive the individual of medical care, such that the individual’s health or life would be endangered; or of food, clothing, shelter, or other necessities of life.

Undue Hardship Waiver- An individual who incurs a sanction for transfer of assets and is denied or terminated from Medicaid payment of institutional services may request this sanction be waived and can demonstrate the sanction will cause the a/r an undue hardship.

Unemployment Insurance (UI) --- Income received by an individual as compensation for loss of employment due to lay-off, suspension, firing; may include additional amounts paid by unions or employers.

Unmet Medical Needs (UMN) --- Medical expenses such as medical insurance premiums, co- payments, charges made by non-participating providers, and Medicare Part B premiums when the recipient is not on the State Buy-In.

Unpredictable Employment --- Employment which is unplanned and arises only from time to time. Income from such employment is not considered available to the budget unit.

Vendor Payment --- A monetary payment made on behalf of a household/ individual by an outside party.

Verification --- The confirmation of information by direct contact with collateral source or personal review of documented information such as a receipt, ledger, or signed statement.

Verification Date --- The date verifying information is received in the county department of social services.

Violence Against Women Act -- Under the Violence Against Women Act (VAWA) passed by Congress in 1994, the spouses and children of United States citizens or lawful permanent residents (LPR) may self-petition to obtain lawful permanent residency. The immigration provisions of VAWA allow certain battered immigrants to file for immigration relief without the abuser's assistance or knowledge, in order to seek safety and independence from the abuser.

Vulnerability --- A household that is totally or partially subject to the rising cost of energy.

North Carolina Department of Health and Human Services AGED, BLIND, AND DISABLED MEDICAID MANUAL

MA-200

DEFINITIONS

33 REISSUED 03/01/11 – CHANGE NO. 03-11 (III.) Wages/Salary --- Compensation paid regularly for services rendered, i.e., baby-sitting in the home of another, sales clerk, EITC.

WFFA (Work First Family Assistance) --- A cash payment and Medicaid for children and parents who meet the income and asset limits for the program. This program is known as TANF at the national level.

Work Programs --- Programs in designated counties that are designated to help an a/r find employment.

Work Release Funds --- Funds to dependents from a prisoner who is employed.

Worker's (Workmen's) Compensation --- Benefits resulting from loss of employment due to injury on the job.

DocuSign Envelope ID: 3289A281-EC13-40C5-A56D-BE1F23756321 North Carolina Department of Health and Human Services Division of Medical Assistance 1

Medicaid Eligibility Unit AGED, BLIND AND DISABLED MEDICAID MANUAL MA-1000

SSI MEDICAID – AUTOMATED PROCESS

REVISED 03/02/2023 – CHANGE NO. 03-23

Current Change Notice: 03-23 • A reminder to refer to MA-2320 and ensure that all policy requirements are followed has been added in section VII.

I. INTRODUCTION TO SSI MEDICAID

North Carolina contracted with the Social Security Administration (SSA) under Section 1634 of the Social Security Act to determine Medicaid eligibility for aged, blind, and disabled individuals who receive SSI. This contract is called a “1634 Agreement” and was effective January 1, 1995. Under this agreement, an application for SSI is also an application for Medicaid. Individuals who are eligible for SSI also qualify for Medicaid. Eligibility for Medicaid begins with the first day of the month in which eligibility for SSI begins and continues as long as the individual remains eligible for SSI.

The SSA determination of SSI Medicaid eligibility includes assessment of categorical requirements, citizenship, income and assets, identification of third party resources and fraud notification. The Eligibility Information System (EIS) issues Medicaid cards and automated notices for these recipients. This is done independently from the issuance of the SSI check. The majority of SSI recipients receive Medicaid without any county dss action or intervention. However, there are special situations which require the county dss to explain and provide services and assistance to SSI Medicaid recipients.

When the SSI terminates, Medicaid may continue without a separate application. The SSI termination appears on the SSI TERMINATION REPORT and the Medicaid remains open. The county department of social services (dss) is responsible for initiating an ex parte review to determine whether the recipient qualifies for Medicaid under any other coverage group, such as Family and Children's Medicaid (including pregnant woman coverage), North Carolina Health Choice for Children, Work First Family Assistance, or Medicaid for the Aged, Blind and Disabled.

The purpose of this section is to explain the automated process which generates Medicaid eligibility based on SSI.

II. POLICY PRINCIPLES FOR SSI MEDICAID

A. SSI recipients are eligible for Medicaid based on receipt of SSI.

B. Ongoing Medicaid eligibility is determined by the Social Security Administration (SSA) for SSI recipients.

C. EIS automatically issues Medicaid benefits and notices to SSI recipients based on receipt of SSI.

DocuSign Envelope ID: 3289A281-EC13-40C5-A56D-BE1F23756321 North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL MA-1000 2

SSI MEDICAID – AUTOMATED PROCESS

(II.) D. The county dss evaluates Medicaid eligibility for SSI recipients when the SSI benefit terminates. The county dss must explore and exhaust all possible avenues of eligibility in other aid program/categories. When the SSI termination is based on no longer being disabled and the SSI recipient timely appeals the SSI decision, his disability status continues through the SSI appeals process. Continue Medicaid benefits as long as he meets non-disability criteria through the SSA appeal process. Refer to MA-2525, Disability, for timeframes on appeals. Refer to VII.D., Continuation of MAD When SSI Disability Termination is in Appeal Status for ex parte procedures. The recipient also has the right to appeal to a State Hearing Officer on the issue of disability if the ex parte process finds him no longer eligible for Medicaid. If the recipient has a non-disability SSI change that results in ineligibility, he may continue to be eligible as MAD or cease to be eligible as MAD. The county dss must explore and exhaust all possible avenues of eligibility in other aid program/categories. III. AUTOMATION OVERVIEW A. State Data Exchange (SDX) SSA transmits information regarding SSI recipients and applicants to the State using the SDX. The State uses information on the SDX to create a Medicaid record in EIS for each SSI recipient. The SDX controls Medicaid eligibility for SSI recipients. Except for the situations identified later in this section, only the SDX can update information in EIS for an SSI recipient. This is true even when the county dss has verified information that is inconsistent with the data on the SDX. Social Security sends SDX updates to the State several times a week. The updates are compiled and processed once a week for Medicaid issuance for SSI recipients. Generally the updates are run on Friday night. The on-line SDX is updated daily as updates are received from Social Security. Therefore, it is possible for an individual to be on the SDX before he is in EIS. B. EIS Uses Information on the SDX To: 1. Create an SSI MAABD case (or modify an existing Medicaid case in EIS to SSI Medicaid). 2. Update case and individual data in EIS for ongoing SSI Medicaid recipients. 3. Issue automated approval, denial, termination and redetermination notices. 4. Issue Medicaid cards for SSI recipients.

DocuSign Envelope ID: 3289A281-EC13-40C5-A56D-BE1F23756321 North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL MA-1000 3

SSI MEDICAID – AUTOMATED PROCESS

(III.B.) 5. Terminate Medicaid when an SSI recipient dies or moves out of state. 6. Change to SSI status when SSI stops. C. SSI Medicaid Recipients In EIS An SSI Medicaid case is in EIS just as a regular Medicaid case is in EIS, with case and individual data and history. 1. SSI Status a. SSI Medicaid Recipients - The SSI status is "Y" for SSI recipients. EIS/SDX controls most of the data on these cases. See III.D., below or refer to the EIS Manual, Section 4200, Part 5. b. SSI Medicaid Recipients In Ex Parte Review Status - The SSI status is "N" and the “Certification Thru Date" is 12/31/9999. Do not make changes to the case in EIS until the ex parte review is completed. c. Non-SSI Medicaid Recipients - The SSI status is "N" for non-SSI recipients. The county dss controls all data on these cases. 2. Aid Program/Category The aid program/category is always MAA, MAB, or MAD except for the following situations: a. SSI recipients who also receive Special Assistance are SAA or SAD. b. SSI children in foster care are HSF. c. SSI recipients in a single person Transitional Medicaid case (payment type 5) remain AAF. 3. Classification SSI recipients are always Categorically Needy. The classification code in EIS is: a. “C” for SSI recipients who do not have Medicare, or b. “Q” for SSI recipients who are entitled to Medicare. 4. Individual Eligibility History (IE) a. The IE segment indicates the individual is an SSI Medicaid recipient beginning with the first month of SSI. b. The certification thru date is always 12/31/9999.

DocuSign Envelope ID: 3289A281-EC13-40C5-A56D-BE1F23756321 North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL MA-1000 4

SSI MEDICAID – AUTOMATED PROCESS

(III.C.4) 5. ID Cards

All SSI recipients receive a gray Medicaid card. For MAABD cases in a private living arrangement (pla), the district number is “SDX” on the EIS case and ID card to indicate the individual is an SSI Medicaid recipient. SAA, SAD, AAF, HSF, and LTC cases retain the district number assigned by the county dss.

D. Creating/Updating an SSI Medicaid Case in EIS

For all SSI recipients, EIS uses information on the SDX to create and update SSI Medicaid cases in EIS. The county dss cannot change data in EIS for SSI recipients, with certain exceptions. (Refer to EIS 4200, Part 5, for a chart which shows all allowable county changes.) This is true even when the county dss has verified information that is inconsistent with data on the SDX.

1. SSI, MAA, MAB, or MAD recipients:

The county dss can update the following fields in EIS:

a. Change the living arrangement from private living arrangement (PLA) to long term care (LTC) and from LTC to PLA.

b. Transfer the case to HSF.

c. Approve a reapplication for money payment (SAA, SAD, AAF).

d. Enter CAP date.

Refer to EIS 4200 Part 5, for instructions.

2. SSI Recipients in Special Assistance (SAA or SAD) or in Single Person AAF case (payment type 5)

The county dss can update some fields in EIS to control the issuance of the check and ensure automatic Medicaid issuance for SSI recipients in these categories. The county dss can also transfer the case to MAABD. Refer to EIS 4200 Part 5, for instructions.

3. SSI Recipients in HSF

The county dss can update some fields in EIS to indicate custody/placement responsibility. The county dss can also transfer the case to MAABD. Refer to EIS 4200 Part 5, for instructions.

DocuSign Envelope ID: 3289A281-EC13-40C5-A56D-BE1F23756321 North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL MA-1000 5

SSI MEDICAID – AUTOMATED PROCESS

(III.) E. Reporting Changes

1. SSI recipients must report to Social Security all changes that affect SSI (including change of address). When Social Security updates the SDX, the change is reflected in EIS. If an SSI recipient reports a change to the dss, instruct him to report the change to the local Social Security Office. Explain that his Medicaid record can only be changed by SSA. Give him the address and phone number of the district office. DO NOT REPORT ROUTINE CHANGES TO SOCIAL SECURITY. IT IS THE RECIPIENT'S RESPONSIBILITY.

2. SSI recipients in LTC, SAD, SAA, HSF, or AAF payment type 5 (situations where the county dss has the capability to update some fields in EIS) must also report changes that affect Medicaid to the county dss. When changes are reported, treat this as change in situation. Update the allowable fields in EIS.

3. When an SSI recipient reports health insurance information to the dss, complete a DMA-2041, Third Party Health and Accident Resources Information. Enter this information in EIS. If the recipient does not have enough information to enable you to complete the DMA-2041, instruct him to obtain the additional information and advise him to contact you with the information as soon as possible.

4. When an SSI recipient also receives Food Stamps or other DSS services, notify the other program immediately of any changes the recipient reports to you.

5. When the dss learns of a change in an SSI Medicaid recipient's situation that might affect his eligibility for SSI and Medicaid, and the client does not/cannot report the change to SSA, use the DMA-5049, Referral to the Local Social Security Office, to report information to the local SSA office. Use this referral only when SSA is not aware of the change in situation. Examples of when to use this referral:

a. DSS learns SSI recipient dies

b. SSI recipient enters a public institution, nursing facility, or rest home

c. DSS learns information that affects SSI payment

d. DSS suspects fraud

6. The county dss may discover information on the SDX is incorrect. The information may not affect SSI eligibility, but it may cause a problem with Medicaid claims, buy-in or some other factor that affects Medicaid eligibility. Use the DMA-5049, Referral to the Local Social Security Office, to report this information immediately to SSA. Use "Other" to specify the problem. SSA must correct its record in order for the SDX to update EIS. For example, the dss verifies an individual is age 64 or less, but the SDX indicates he is 65. Medicaid claims will be denied until the problem is corrected.

DocuSign Envelope ID: 3289A281-EC13-40C5-A56D-BE1F23756321 North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL MA-1000 6

SSI MEDICAID – AUTOMATED PROCESS

(III.E.) 7. In the unusual situation that SSA does not react to changes reported by the client or dss and it is causing a hardship for a recipient or provider, contact DMA, Medicaid Eligibility Unit. A policy consultant will work with you on a case by case basis.

F. Buy-In

SSI recipients who are eligible for Medicare are automatically accreted for buy-in by SSA. Buy-in is effective the first month of Medicaid eligibility. SSI recipients remain on buy-in until Medicaid is terminated. See MA-2410, Medicare Enrollment and Buy-In.

IV. SSI APPROVAL

When SSI is approved for an individual, the information on the SDX is matched to EIS to determine if the SSI individual is already in EIS. The purpose of matching is to prevent duplicate EIS individual ID's and benefits. If the individual is not in EIS, EIS creates a new case. If the individual is found in EIS, EIS creates a new case for the individual and closes or deletes him from the existing case, or in some cases modifies the existing case. Refer to EIS 4200, Part 3 for information. Also follow instructions in MA-1100, SSI Medicaid/County DSS Responsibility for county dss responsibility when an active Medicaid recipient or applicant in EIS is approved for SSI.

When the Social Security Number of an individual on the SDX matches with an individual in EIS but one of the other criteria does not match or the social security number is found more than once in EIS, EIS creates an exception report called the "SDX Exception List" which is online in EIS. The county dss must determine if the individuals are the same. It is very important to work the exception report weekly. See EIS 4200, Part 2 for instructions to resolve the discrepancies. UNTIL THE DISCREPANCY IS RESOLVED, EIS CANNOT PROCESS THE SSI MEDICAID CASE AND/OR ISSUE MEDICAID.

A. Reports

To assist with case management, EIS generates the report "SSI Medicaid Created/Modified in EIS" when a current EIS case or individual is modified as a result of an SSI approval, and when an SSI Medicaid case transfers into a county. These reports are displayed in NCXPTR. The last six versions are kept on-line. Each situation is identified separately. The EIS county number, district, aid program/category, casehead, case number, case id, SSI recipient name, and individual ID number are listed for each case. Any pending action deleted by EIS as a result of a case termination is also listed.

Refer to EIS 4200, Part 8 for instructions for this report.

See below for a chart of all the SSI Medicaid reports.

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(IV. A.) SSI REPORTS Name of Report What It Lists Sorted By Online or Paper SSI Medicaid Cases Created/Modified by EIS Cases created/modified/terminated by EIS due to SDX Updates 1) Case Terminated 2) Individual Delete 3) SSI Medicaid 4) Review 5) New Individual 6) County Transfer 7) Inactive County, District, message type, and alpha by last name NCXPTR – last 6 versions SSI Individual In EIS Pending Application SSI Individual who had a pending application in EIS but now authorized for SSI Medicaid County, District, and date of application (oldest first) NCXPTR – Applications listed are retained on the report until dispositioned SSI/Medicaid ID Registers SSI Medicaid Straggler Run/Register Cards generated for SSI Medicaid recipients 1) Annual Run 2) Daily/Weekly Straggler Alpha by name NCXPTR – last 25 versions SSI Approval-Medicaid Denied (TPR Refusal) Denied due to failure to provide TPR info – SDX code - R County, alpha by name NCXPTR – last 8 versions Medicaid Terminated – (TPR Refusal) Medicaid terminated due to failure to provide TPR info – SDX code – R County, District, program, and alpha by name Paper mailed to the county SSI Individual Receiving SAA/SAD/HSF List of cases where client failed to provide TPR info, SDX code – R District, program, alpha by name Paper mailed to the county SSI Exempt Persons exempt from participation in Carolina Access Exempt #, alpha by name Paper mailed to the county SSI Termination Report Termination due to redetermination, death, moving out of state District, post date, type action NCXPTR - Case continues to display until the county processes the termination and deletes the case SSI Termination Alert Report The county has not redetermined eligibility, terminated the case, SSI has not been reapproved or a reapplication has not been dispositioned. County, post date, alpha name NCXPTR – Case continues to display until the county processes a redetermination.

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(IV.) B. Approval Notice

When SSI is approved and an SSI Medicaid case is created in EIS, an automated Medicaid approval notice is generated that night. See DMA-5101, SSI Approval Notice.

C. Medicaid Card Issuance

1. For new SSI approvals, EIS issues Medicaid cards for SSI Medicaid approvals the same night the case is created in EIS. The State mails the cards from Raleigh the next work day. EIS generates the SSI Medicaid Straggler Register daily in NCXPTR.

2. Ongoing SSI Medicaid recipients are issued a yearly Medicaid card by EIS. An SSI/Medicaid Regular Run Register is generated in NCXPTR for identification. Regular run is the 11th work night from the end of the month.

V. LIMITATIONS TO MEDICAID ELIGIBILITY FOR SSI RECIPIENTS

A. Refusal to Provide Third Party Resource (TPR) Information

Providing TPR is not a requirement for SSI, but it is a requirement for all Medicaid programs. When an SSI applicant refuses to provide TPR to SSA, he is advised by SSA that he is not eligible for Medicaid. No action is required by the dss until the recipient contacts the dss.

1. Identification

a. Individuals who refuse to provide TPR information are indicated on the SDX by an “R” for the Medicaid Eligibility Code and an "R" for the Third Party Insurance indicator.

b. This information is also reported on either the SSI Approval -Medicaid Denial (TPR Refusal) Report (see V.A.2., below) or the TPR Refusal - Medicaid Terminated Report (see V.A.3., below). Refer to EIS 4200 for further information on these reports.

NOTE: Active SAA, SAD, and HSF cases are not terminated. TPR refusal is reported on the TPR REFUSAL-SSI INDIVIDUAL RECEIVING SAA/SAD/HSF Report. This report is for informational purposes.

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(V.A.) 2. SSI Approval/Medicaid Denial (TPR Refusal) Report

a. For an SSI approval/Medicaid denial, EIS does not create a Medicaid case or generate a Medicaid card.

b. EIS sends an automated Medicaid denial notice. See DMA-5103D, SSI Denial Notice.

3. SSI Approval/Medicaid Terminated Report (except SAA, SAD, or HSF)

a. When the individual is in a single person case, the case is terminated.

b. When the individual is in a multiple person case, the individual is deleted from the case.

c. EIS sends an automated termination notice. See DMA-5103T, SSI Termination Notice.

4. Appeal Rights

a. The individual is advised in the denial or termination notice that:

(1) He may request an appeal to his county dss within 60 days from the date of the notice if he does not agree with the denial or termination, or

(2) He can become eligible for Medicaid by providing TPR information to the local county dss.

b. If the individual contacts the county dss and requests an appeal, follow procedures for local hearings in MA-2420, Notice and Hearings Process, for local hearings. Prepare a summary which states: “Social Security has advised the State that you refused to provide medical insurance information.”

c. The Medicaid denial or termination can be reversed only when the individual provides his insurance information. This can be done at the appeal or any time the information is provided.

d. When the recipient provides the necessary medical insurance information:

(1) Use the DMA-5049, Referral to Local Social Security Office, to inform the local SSA office that the recipient has provided the necessary medical insurance information. Request that SSA delete the “R” code from the recipient's record. When the SSA record is updated, this information will be transmitted to the State via the SDX.

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(V.A.4.d.) (2) When the SSI Medicaid case is created, complete the DMA-2041, Third Party Health and Accident Resources Information, and enter the insurance information in EIS.

The individual will not receive SSI Medicaid until the corrected information is transmitted to EIS via the SDX. EIS will then automatically create an SSI Medicaid case and issue a notice and card effective the month SSI is effective. B. Trusts

Certain trusts are not a countable resource in determining SSI eligibility. They may be a countable asset for Medicaid, and therefore affect Medicaid eligibility. When the SDX indicates the individual has a certain trust, EIS will generate a report to DMA.

The DMA Medicaid Eligibility Unit will send notification to the county along with a copy of the EIS report. The county will evaluate the report for effect on eligibility.

VI. SSI DENIAL

A. SSI Denial/Medicaid Denial

When SSI is denied, SSI Medicaid is automatically denied. EIS sends an automated Notice of Medicaid Denial. See DMA-5102, SSI Denial Notice. There is no notice register for denials.

B. Appeals for Medicaid Denial

When SSA denies SSI and Medicaid, the individual must contact Social Security to appeal the denial of his SSI and Medicaid. The Notice of Medicaid Denial advises the individual to contact SSA to appeal and advises him to contact dss if he wants to be evaluated under another coverage group.

VII. SSI TERMINATIONS

Caseworkers must refer to MA-2320, Recertification, and ensure that all policy requirements are followed for SSI Exparte reviews.

When SSI terminates, evaluate ongoing eligibility for Medicaid in all aid program/categories. The individual remains authorized after SSI is terminated while the evaluation is completed.

When the SSI termination processes in EIS, the termination appears on the SSI TERMINATION REPORT. The SSI indicator changes to "N." The case remains open with a Medicaid through date of 12/31/9999. Within 5 workdays the county dss must initiate an ex parte review to determine whether the recipient qualifies for Medicaid under any other coverage group, including Family and Children's Medicaid which includes pregnant woman coverage, family planning waiver, North Carolina Health Choice for Children, or Work First Family Assistance. For SSI terminations for disability reasons, see D. for ex parte procedures.

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(VII.) A. Automated Recipient Notice

When the SDX indicates a recipient is being terminated from SSI, EIS generates an automated notice to the recipient. See DMA-5100, Notice of Medicaid Redetermination.

The notice advises the recipient:

1. To contact the local SSA if he wants to appeal the SSI termination.

2. The county dss must determine whether he may continue to be eligible for Medicaid as a non-SSI recipient.

3. The county dss will contact him if further information is needed.

When the determination is completed, a timely notice will be sent to inform the recipient of the Medicaid decision.

B. Time Frames for Completing the Evaluation of Ongoing Medicaid Eligibility (Ex Parte Review)

1. Initiate the evaluation of ongoing eligibility within 5 workdays of the date the termination appears on the SSI TERMINATION REPORT. This is essential to ensure enough time to evaluate for ongoing eligibility.

Use the Adult Medicaid Applications or the DMA-5007, MAABD Redetermination Document, as the base document for the evaluation for ongoing eligibility. The SSI recipient's signature is not required for the evaluation, nor can the recipient be required to come into the agency.

Within 4 months of the month the SSI terminated, the county dss must complete the evaluation of ongoing eligibility and notify the recipient about his ongoing eligibility for Medicaid. The four month period begins the month the case appears on the SSI TERMINATION REPORT.

For example, the case appears on the SSI TERMINATION REPORT in July. July, August, September and October are continuation months. Complete the evaluation of eligibility and send the timely notice to make the decision effective no later than October 31.

2. Federal financial participation for up to four months is available for Medicaid during the evaluation. Counties may be liable for charge backs of Medicaid expenditures for ineligible cases if the Medicaid must be extended longer than 4 months to complete an evaluation and/or send timely notice of termination.

3. Recipient Lives In A County Different From That On The SSI TERMINATION REPORT.

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(VII.B.) If the recipient lives in another county, the county dss in which the SSI TERMINATION REPORT appears must contact the dss in the county of residence immediately and tell them of the SSI termination. Within 5 workdays the first county must send a copy of the SSI TERMINATION REPORT to the county of residence who must complete the evaluation. Once completed, the first county must be notified so they can key in the results of the evaluation and, if eligibility continues, transfer the case to the county of residence. Cooperation between the two counties is essential to ensure that the evaluation for ongoing coverage is completed timely and there is no break in coverage for the recipient.

C. Medicaid Evaluation for Ongoing Eligibility - Ex Parte Review Procedures The term “ex parte review” means to review information available to the agency to make a determination of eligibility, without requiring the recipient to come into the agency or make a separate application. The county must explore and exhaust all possible avenues of eligibility in all Medicaid coverage groups. If information is not available to make a determination of eligibility, the county must provide the recipient reasonable opportunity to provide the necessary information. Do not require citizenship/identity documentation during an ex parte review. See MA-2506, US Citizenship Requirements. 1. What Information Must be Reviewed Review only those eligibility factors that are subject to change, such as income or resources. Do not reverify factors that are not subject to change, such as date of birth or citizenship. 2. Where to Look For Possible Sources of Information Review all possible sources of information available to the agency, including information verified by other programs. Medicaid eligibility is determined according to the rules of the appropriate Medicaid coverage group. However, the county must accept as accurate verifications from other programs, including: a. Information available through automated queries, such as SDX, BENDEX, TPQY, SOLQ, ESC, ACTS and FSIS. (Refer to MA-2430, Automated Inquiry and Match Procedures, and EIS 1103 for instructions on using the SDX, BENDEX, SOLQ and other online inquiries.) b. Information collected in the determination of eligibility for other programs, such as Food Stamps, Work First, child care assistance, IV-D child support services and adult or children's services, if the information can be released by the other programs within its rules for confidentiality. For example, child protective services records may not be available. c. Information that is current. "Current" means that the information was obtained and verified by the other program within the time frames for redeterminations of eligibility for the Medicaid coverage group being considered, unless there is reason to believe it is inaccurate.

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(VII.C.2.c) Current also means that the case is active. Information obtained from a closed or terminated program is not considered current even if verified during the appropriate time frames. A case in suspense is considered active. For SSI terminations, information on the SDX is no longer current as the SSI case is no longer active. Income, resources and other information subject to change must be verified. The former SSI recipient is exempt from citizenship/identity requirements. Use citizenship/identity code 50, permanently exempt. For example, if the recipient is being evaluated for MAF Medically Needy and the certification period is 6 months, the information must have been verified within the last 6 months. If the recipient is being evaluated for MIC and the certification period is 12 months, the information must have been verified within the last 12 months. In both situations the case in the other program must be currently active. 3. Whose Information to Review a. Check all possible sources of information in the SSI recipient's name. b. If the names of immediate family members (spouse, parents and stepparents, adult or minor children, and siblings) who live with the recipient are known, check all records in their names. See DMA-5138, Ex Parte Review Checklist (Non-MIC/NCHC Re-Enrollments), for a suggested checklist to document family members.

D. Continuation of MAD When SSI Disability Termination is in Appeal Status - Ex Parte Procedures When the SSI disability benefit of an active MAD recipient is terminated for no longer being disabled, he or she may continue to be considered disabled while pursuing appeal of the SSI termination. The recipient has only 65 days to request an appeal with Social Security/SSI unless SSA accepts a late appeal for good cause. 1. The case will appear on the SSI Termination Report. Begin the ex parte review process in five work days. a. If the recipient appeals the SSI termination within 65 days or SSA accepts the appeal with good cause and the recipient meets other non-disability criteria for MAD, the ex parte review is complete. Flag the case and continue to track the SSI appeal according to MA-2525, Disability. Determine if the recipient is receiving Medicare Part B. Contact the Social Security Administration to determine if the recipient will continue receiving Medicare Part B while the SSI termination is being appealed. If necessary, change the classification code from Q or B to N or M when the Medicaid is continued but the recipient no longer receives his Medicare benefit.

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(VII.D.1.) b. If the recipient does not appeal the SSI termination timely, the recipient is no longer considered disabled and is ineligible for MAD when: (1) He ceases to pursue the SSI appeal up to the appeals council,

(2) SSA doesn’t accept the appeal for a good cause reason.

2. Begin the process by evaluating eligibility in all coverage groups. Use all agency verifications to determine eligibility before contacting the a/r. Use the DMA-5180, SSI Check Terminated: Information Needed to Determine Medicaid Eligibility, to contact the a/r. If additional information is needed, use the DMA-5097, Request for Information. a. If the recipient remains eligible in another category, immediately transfer the case to that aid program category.

b. The county must complete the ex-parte review process in four months. The four months begin the month the case appears on the SSI termination report.

c. If the recipient is not eligible in another category, terminate the case after timely notice.

3. If the recipient appeals the county’s decision to terminate the case and recipient alleges he is still disabled, request a state hearing. The State Hearing Officer determines if the recipient meets one of the conditions in a., b., or c.

a. Has a disabling condition different from, or in addition to the conditions considered in the original SSA disability decision, or

b. Alleges more than 12 months after the most recent SSA termination for not being disabled that his condition has changed or deteriorated and his period of disability meets the 12 month durational requirement, and he has not reapplied at SSA based on those new allegations, or

c. Alleges less than 12 months after the most recent SSA termination for not being disabled, that his condition has changed or deteriorated, and his period of disability meets the 12 month durational requirement, and

(1) He has applied to SSA for reconsideration or reopening and SSA refuses to consider the changes, and /or

(2) He does not meet other SSI eligibility requirements e.g., reserve, but may meet the state’s Medicaid eligibility requirements for MAD.

4. If the State Hearing Officer determines that a., b., or c. applies, then the State Hearing Officer will determine if the recipient meets the disability requirements. If the Hearing Officer determines the recipient is still disabled, MAD is continued or reinstated.

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(VII.D.4.) A continuing SSA appeal is not a requirement if the hearing officer determines that 3. a., b., or c. applies and that the a/r is disabled.

E. Evaluate All Coverage Groups

Evaluate the recipient's eligibility in all coverage groups. This may involve contacting the recipient to obtain additional information, ONLY if necessary information is unavailable to the agency from another source or is not current. See F.

If the recipient is eligible in more than one coverage group, the recipient has a right to choose the coverage group. Explain the advantages of each coverage group and document the recipient's choice.

1. MAD - Refer to D. for continuation of MAD when SSI disability termination is in appeal status.

If the recipient’s SSI was terminated for a non-disability related reason, such as income, evaluate for MAD. If the recipient remains eligible, as MAD, continue MAD. At the next regular eligibility redetermination, submit forms to DDS to establish a regular “Diary/Re-Exam Date” for ongoing reviews of disability.

2. Children Terminated from SSI With Protected Status - Refer to MA-2525, Disability, for instructions for evaluating children with protected status.

3. MAA - If the individual is aged 65 or older, evaluate for MAA.

4. MAB - If the individual has been determined to be blind by Social Security, evaluate for MAB.

5. MAF - Evaluate for MAF-C. If it appears the recipient is eligible for MAF-C, then, advise a/r to apply for Work First. However, approve him for MAF-C if eligible. If the SSI recipient’s family is authorized for Work First, the former SSI recipient must be added to the Work First assistance unit.

6. Other Family and Children's Medicaid

a. Evaluate the recipient's eligibility in all Family & Children's categories, including MAF, MIC, NCHC, HSF, MPW, Breast and Cervical Cancer Medicaid and Family Planning Waiver.

b. If it is known to the agency that the recipient is pregnant, contact the recipient to request verification of pregnancy to evaluate for MPW. If there is no information to indicate pregnancy, continue to evaluate in other coverage groups. It may be necessary to contact the recipient to inquire whether she is pregnant if there is no other basis for eligibility. See instructions in F.

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(VII.E.) c. Medicaid Family Planning Waiver (FPW) – If the recipient is a female age 19 through 55 or a male age 19 through 60, with an income at or below 185% of the federal poverty level, and is not eligible for any other coverage group, evaluate for FPW.

7. North Carolina Health Choice for Children - If the recipient is up to age 19 and is not eligible for Medicaid in any other coverage group, evaluate for North Carolina Health Choice for Children.

F. When and How To Request Information From The Recipient

Information must be requested from the recipient only when it is necessary to determine ongoing eligibility AND the information is not already available to the agency or is not current as described in C.2.

1. Necessary information may be requested by telephone or in writing. If a telephone request is made, advise the recipient what information is needed and that he may request additional time or assistance in obtaining necessary information. Document the record to show the date of the telephone contact, the specific information requested and that the recipient was offered assistance. If the request is in writing, use the DMA-5097, Request for Information.

2. Allow the recipient at least 12 calendar days from the date of the request to provide the information. For example, if a DMA-5097, Request for Information is mailed on January 7 to request current wage information, the deadline for providing the information is January 19.

3. If the recipient does not provide the requested information by the deadline, send timely notice proposing termination for failure to provide the necessary information.

4. Letter to Recipient Prior to Termination

There may be situations in which there is little or no information in the agency regarding an SSI recipient. If you complete the evaluation above and the only potential coverage groups available are in Family & Children's Medicaid, eligibility cannot be established without determining if the recipient is pregnant or has minor children living in the home.

For example, a 34 year old SSI recipient is terminated because she is no longer disabled. She does not receive any other services and is not known to the agency. She could potentially be eligible for MPW if she is pregnant or as an MAF caretaker if she has minor children living with her. If she appeals the SSI termination timely, she can continue to receive MAD.

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(VII.F.4.) a. Send a DMA-5180, SSI Check Terminated: Information Needed to Determine Medicaid Eligibility, to the recipient advising that Medicaid eligibility is being evaluated and additional information is needed. This letter asks if the recipient is pregnant or has minor children living in the home. The letter also explains the Medicaid Family Planning Waiver and asks the recipient if he wishes to apply.

b. Allow the recipient at least 12 calendar days to return the letter or contact the agency. If the recipient contacts the agency by the deadline, the recipient may request additional time to obtain necessary information such as pregnancy verification.

If the recipient answers yes to either question but provides no other information, contact the recipient to determine if he needs assistance obtaining documentation. Document all efforts to assist the recipient.

c. If there is no response to the letter by the deadline date, either by phone or in writing or in person, and the recipient is not eligible in any other category, send a timely notice to propose termination.

G. Results of Evaluation for Ongoing Eligibility

1. When all necessary information has been obtained and/or requested, determine whether the recipient is eligible for Medicaid under any aid program/category. One of several eligibility outcomes is possible:

a. Recipient is eligible for full Medicaid (MAABD or Family & Children's Medicaid) without a deductible; or

b. Recipient will be eligible for full Medicaid (MAABD or Family & Children's Medicaid) if he meets a deductible (Medically Needy), or recipient is eligible as MQB, Q, B, or E, Family Planning Waiver or Breast and Cervical Cancer Medicaid; or

c. Recipient is eligible for North Carolina Health Choice for Children; or

d. Recipient is ineligible for Work First; or

e. Recipient is ineligible for any Medicaid coverage; or

f. Recipient did not provide necessary information and coverage must be terminated after timely notice.

2. It is also possible that an additional application may be necessary if the recipient requests assistance for other family members, such as a spouse or children, during the review. Treat the request for additional coverage as a separate application.

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REISSUED 11/01/11 – CHANGE NO. 17-11 (VII.G.) 3. If eligibility is established in any coverage group, the certification period begins with the current processing month in EIS.

Example: Review completed January 27. The current EIS processing month is March. The new certification period begins March 1.

4. If the recipient is eligible as MQB (Q, B or E) only, transfer the case to MQB.

5. Deductible Cases

a. If the recipient is eligible for Medicaid but must meet a deductible, contact the recipient regarding his predicted or outstanding medical expenses to determine if he can meet the deductible.

He can if:

(1) His deductible amount is $300 or less, or

(2) His predicted expenses or old bills are within $300 of meeting the deductible.

b. If it is determined that the recipient can meet his MAABD deductible:

(1) Certify and put the case in deductible status.

(2) Follow deductible policy in MA-2360, Medicaid Deductible, to apply medical expenses to the deductible.

(3) Indicate the deductible amount on the automated notice.

c. If it is determined that the recipient can meet an MAF deductible:

(1) Terminate the MAABD case.

(2) Enter an administrative DSS-8124 to open an MAF case.

(3) Pend the application to meet the deductible. (MAF cases cannot be approved in EIS in deductible status.)

d. If it is determined that the recipient's deductible is greater than $300 or the predicted medical expenses are not within $300 of meeting the deductible, send timely notice to propose termination.

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REISSUED 11/01/11 – CHANGE NO. 17-11 (VII.G.) 6. MIC or MAF Cases

a. Caretakers for SSI children must cooperate with IV-D to establish medical support agreements when the following applies:

(1) The caretaker is applying for or receiving Medicaid for herself in any aid/program category except MPW. Refer to MA-2375, Procedures for Child Support Enforcement.

OR

(2) The child meets the criteria listed in MA-2375, Procedures for Child Support Enforcement.

b. If the recipient is eligible as MIC or MAF, terminate the MAABD case. Enter an administrative DSS-8124 to open an MIC or MAF case.

7. MAF Caretaker Evaluation

a. To receive as a caretaker, the individual must be living with and caring for a child under age 19 who is a citizen or alien lawfully admitted for permanent residence (LPR).

b. If the county dss knows that the recipient has at least one minor child living in the home for whom care is provided, the caretaker requirement is met.

H. Termination of the MAABD Case

1. Send timely notice to propose termination of Medicaid ONLY IF:

a. Information necessary to determine ongoing eligibility is unavailable to agency or is not current, and

b. The information was requested from the recipient according to requirements in this section (VII.), and

c. The recipient did not respond by the deadlines required in this section, OR

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REISSUED 11/01/11 – CHANGE NO. 17-11 (VII.H.1.) d. All procedures in this section were followed and the recipient does not meet the eligibility requirements for Medicaid in any aid program/category. The assistance may be terminated with timely notice prior to the end of the 4 month period if all ex parte requirements have been met.

2. The recipient may rebut the information stated on the timely notice as the reason for termination within the timely notice period. Always use a termination reason code that most accurately describes the reason for ineligibility.

VIII. SSI OPEN/SHUTS

Sometimes SSI is approved for a finite period in the past. If the individual comes to the dss with an approval letter for a prior period, determine if the individual is on the SSI TERMINATION REPORT.

If the individual is on the SSI TERMINATION REPORT, follow the procedures in VII. If the individual is not on the SSI TERMINATION REPORT, take an application. Follow application procedures in MA-2300 through MA-2304. Refer to EIS 4200 Part Four for instructions for SSI Open/Shut cases.

North Carolina Department of Health and Human Services Division of Medical Assistance Medicaid Eligibility Unit AGED, BLIND AND DISABLED MEDICAID MANUAL

MA-1100

AGED, BLIND AND DISABLED

SSI MEDICAID – COUNTY DSS RESPONSIBILITY

1 MA-1100 SSI MEDICAID-COUNTY DSS RESPONSIBILITY REVISED 11/01/11 – CHANGE NO. 17-11

I. COUNTY DSS RESPONSIBILITY FOR SSI APPROVALS

This section provides instructions for situations in which the county dss may have interaction with SSI Medicaid recipients.

A. SSI Approval with Pending Application in EIS

1. Each individual in a pending application in EIS who begins to receive SSI is identified to the county dss on the report: DHREJ SSI IND IN EIS PENDING APP. This report is generated in XPTR at the time of the SDX weekly update. The application remains on the report until it is dispositioned. Refer to EIS 4200 for additional information on the report.

2. When SSI is approved, EIS creates an SSI Medicaid case for the individual and authorizes Medicaid effective the first month SSI is approved.

a. The pending application is not altered in any way.

b. The county dss must approve, deny, or withdraw its application.

c. Continue to follow application processing requirements in MA-2300, Initial Contact, through MA-2304, Processing the Application.

3. Single Person Application

a. Continue to process the application beginning with the month of application (ongoing and retroactive) through the month prior to SSI Medicaid authorization.

b. If the individual has a deductible, recalculate the ongoing deductible based on the income in the months beginning with the month of application through the last month prior to SSI Medicaid authorization.

c. Use the DMA-5097/DMA-5097S, Request For Information, or the DMA- 5099/DMA-5099S, Medicaid Application Pending For A Deductible, to notify the individual of the revised deductible.

d. If the application is approved for the period prior to SSI authorization, approve open/shut.

e. If the individual is ineligible for Medicaid prior to SSI Medicaid authorization, deny the application per MA-2304, Processing the Application.

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL

MA-1100 AGED, BLIND AND DISABLED

SSI MEDICAID – COUNTY DSS RESPONSIBILITY

2 REISSUED 11/01/11 – CHANGE NO. 17-11 (I.A.) 4. Multiple Person Application (MAF, MIC, AAF)

a. Continue to process the application for the remaining individuals in the application.

b. Do not count the SSI individual's needs, income, or resources beginning with the month of SSI Medicaid authorization. Recalculate the deductible, if applicable.

c. Adjust the maintenance allowance for the remaining applicants effective the month the SSI individual's needs are deleted.

B. SSI Approval with Authorized Single Person Case in EIS

1. Each individual in an authorized single person case in EIS (except HSF, SA, AAF payment type 5) who begins to receive SSI is identified to the county dss on the DHREJ SSI MED CREATED/MODIFIED Report. The message is: CAS TRM- EIS has created an SSI Medicaid case. This report is generated in XPTR each time EIS is modified as a result of an SSI approval. Refer to EIS 4200 for additional information on the report.

2. When a single individual who is already authorized in EIS in any aid program/category is approved for SSI no further action is required.

3. For a married individual whose spouse is receiving non-SSI Medicaid:

a. React to the change in 30 days.

b. Treat the spouse as a budget unit of one.

c. Delete the SSI individual's needs, income, and resources from the spouse's budget effective the month of SSI Medicaid authorization. Apply the Maintenance Allowance adjustment.

d. Refer to MA-2340, Change in Situation, for instructions on deleting a budget unit member.

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL

MA-1100 AGED, BLIND AND DISABLED

SSI MEDICAID – COUNTY DSS RESPONSIBILITY

3 REVISED 10/01/05 - CHANGE NO. 28-05 (I.) C. SSI Approval With Authorized Multiple Person Case in EIS (MAF, MIC, AAF)

1. Each individual in an authorized multiple person case in EIS who begins to receive SSI is identified to the county dss on the DHREJ SSI MED CREATED/MODIFIED Report. The message is: IND DEL-EIS has created an SSI Medicaid case. This report is generated in XPTR each time a case in EIS is modified as a result of an SSI approval. Refer to EIS 4200 for additional information on the report.

2. React to the non-SSI case within 30 days.

3. Delete the SSI individual's income from the ongoing non-SSI case effective the month of SSI Medicaid authorization.

4. Change the maintenance allowance to delete the SSI individual's need.

5. If the change causes the case to have a deductible, send a timely notice.

6. Refer to the Family and Children’s Manual, MA-3410, Terminations and Deletions for instructions on deleting an assistance unit member.

D. SSI Approval with Deductible Case in EIS (MAABD or MAF)

1. An SSI approval for an individual in a single person MAABD or MAF case in deductible status in EIS is identified to the county dss on the DHREJ SSI MED CREATED/MODIFIED Report. The message is: CAS TRM-EIS has created an SSI Medicaid case. This report is generated in XPTR each time a case in EIS is modified as a result of an SSI approval. Refer to EIS 4200 for additional information on the report.

2. SSI Medicaid is authorized effective the month of approval for SSI, but not prior to January 1, 1995.

a. Recompute the six month deductible based only on the income in the months in the certification period prior to SSI Medicaid authorization.

b. Notify the individual of the revised deductible.

c. If the revised deductible is met, authorize for the period of time prior to SSI Medicaid authorization.

3. If the SSI individual has a non-SSI spouse, review the spouse's case:

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL

MA-1100 AGED, BLIND AND DISABLED

SSI MEDICAID – COUNTY DSS RESPONSIBILITY

4 REVISED 10/01/05 - CHANGE NO. 28-05 (I.D.3)

a. Treat the non-SSI spouse as a budget unit of one effective the month the SSI individual is authorized for SSI Medicaid. Apply Maintenance Allowance Adjustment.

b. Follow MA-2340, Change In Situation, or Family and Children’s Manual, MA-3410, Terminations and Deletions, for instructions to delete budget unit members.

4. If the SSI recipient is in deductible status in a multiple person MAF case the message is: IND DEL-EIS has created an SSI Medicaid case.

a. Recalculate the six month deductible based on the number of months the SSI individual was in the certification period.

b. Delete the SSI individual from the budget unit effective the month of SSI Medicaid authorization.

c. Notify the ongoing MAF case of the amount of the new deductible.

E. SSI Approval with MQB Case in EIS

1. Each individual in an authorized MQB case in EIS who begins to receive SSI is identified to the county dss on the DHREJ SSI MED CREATED/MODIFIED Report. The message is: CAS TRM-EIS has created an SSI Medicaid case. This report is generated in XPTR each time an MQB case in EIS is terminated and a MAABD case is created as a result of an SSI approval. Refer to EIS 4200 for additional information on the report.

2. If the MQB recipient was on a deductible, follow instructions in D. above, to recalculate the six month deductible for the SSI individual for the period prior to the SSI Medicaid authorization.

F. SSI Approval with Existing HSF Case

1. When an authorized HSF recipient is approved for SSI, the SSI status is set to "Y". The case remains in HSF. This situation is not identified on the DHREJ SSI MED CREATED/MODIFIED Report.

2. If the HSF case is in deductible status, the SSI status is set to "Y" and the case is automatically authorized effective the month of SSI approval. Individuals in HSF who go from deductible status to authorized are identified on the DHREJ SSI MED CREATED/MODIFIED Report. The message is: SSI MED-Non-SSI EIS cases that change to SSI Medicaid. Follow instructions in D., above to recompute the deductible for the time prior to SSI Medicaid authorization, if applicable.

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL

MA-1100 AGED, BLIND AND DISABLED

SSI MEDICAID – COUNTY DSS RESPONSIBILITY

5 REVISED 10/01/05 – CHANGE NO. 28-05 (I.F.) 3. The county dss continues to be responsible for county custody and placement.

4. The county dss retains the capability to update address, county, district number, and county case number. The following fields cannot be updated:

a. SSI status b. Certification thru c. RSDI Claim number d. First Name, Middle Initial, Last Name e. SSN f. Date of Birth g. Sex

G. SSI Approval With Existing SAA or SAD Case

1. When an individual in SAA or SAD is approved for SSI, the case remains in SAA or SAD.

2. EIS sets the SSI status to “Y”. This prohibits the county dss from terminating Medicaid even when SAA or SAD terminates.

3. Refer to the Special Assistance Manual for further instructions for SA recipients.

H. SSI Approval with Existing AAF Case

1. Single Person Case

a. For AAF (payment type 1, 2, S, or 4) the case is closed. An SSI Medicaid case is created for the individual.

b. For AAF (payment type 5) case, EIS sets the SSI status to "Y." The case remains AAF. The individual will receive automatic Medicaid.

2. Multiple Person Case (All payment types)

a. The SSI individual is deleted from the case. An SSI Medicaid case is created for the individual.

b. The AAF case is not altered in any other way.

Refer to the Work First Manual for instructions for AAF cases.

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL

MA-1100 AGED, BLIND AND DISABLED

SSI MEDICAID – COUNTY DSS RESPONSIBILITY

6 REISSUED 10/01/05 – CHANGE NO. 28-05

II. COUNTY DSS RESPONSIBILITY FOR RETROACTIVE SSI MEDICAID

This section applies ONLY to individuals requesting retroactive Medicaid based on an SSI date of application. Individuals can also apply for retroactive Medicaid based on the Medicaid date of application at the dss. Refer to MA-2301, Conducting A Face To Face Intake Interview, for procedures when accepting and processing non-SSI retroactive Medicaid applications.

A. Policy Rules

1. The retroactive period for SSI Medicaid is the 1, 2, or 3 month period prior to the SSI month of application. This date is protected for any Medicaid coverage group.

2. An individual cannot apply for retroactive SSI Medicaid until his SSI application is disposed.

3. The a/r must apply for retroactive SSI Medicaid within 60 days (90 days with good cause) from the date of the SSI Medicaid approval or denial notice in order to protect the SSI retroactive period.

B. Establish Timely Application

1. Verify that the request for retroactive Medicaid is within 60 days of the date of the SSI Medicaid disposition notice generated by EIS:

a. View applicant's Medicaid approval or denial notice. The 60 day period begins with the Date Mailed on the Notice, or

b. Verify the case create date on the case data (cd) screen in EIS. This is the date the Medicaid notice is mailed. The 60 day period begins with the date the Medicaid notice was mailed,

or

c. Verify via the on-line SDX the date of SSI denial. The 60 day period begins with the date of the first Saturday after the SSI denial. This is the date the Medicaid notice is mailed. (Use this method to establish the date of the notice only when the applicant cannot provide his SSI Medicaid denial notice).

2. When more than 60 days but less than 90 days have elapsed, determine if good cause exists for failure to apply timely. Good cause is limited to:

a. The applicant states he did not receive the SSI Medicaid notice; or

b. The applicant dies; or

c. The applicant is incapacitated, incompetent, or unconscious and there is no representative acting on his behalf; or

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL

MA-1100 AGED, BLIND AND DISABLED

SSI MEDICAID – COUNTY DSS RESPONSIBILITY

7 REISSUED 10/01/05 – CHANGE NO. 28-05 (II.B.) d. The applicant or spouse, child, or parent, or representative of applicant is hospitalized for an extended period of time.

3. DO NOT TAKE AN APPLICATION FOR RETROACTIVE SSI MEDICAID WHEN THE REQUEST IS NOT TIMELY.

C. Establish the Retroactive Period

1. The retroactive period is the 1, 2, or 3 month period prior to the SSI month of application.

2. Always use the date in the SSI Application Date field to verify the retroactive period. It is located on screen two of the on-line SDX.

D. Register a DSS-8124

1. The application date entered on the DSS-8124 is the date the retroactive application is signed at the county dss. This is a new application, not a reapplication.

2. Enter the exact first and last name, Social Security number, and birth date as listed on the SDX.

IMPORTANT: EIS DATA MUST MATCH SDX DATA TO PREVENT FUTURE DISCREPANCIES.

3. Use the EIS individual ID number assigned to this individual.

4. The application must be MAA, MAD, or MAB.

5. On the retro date screen, place an S beside RSDI Or SSI Appeal Reversal/SSI APPL to indicate this is an SSI Retroactive application.

NOTE: Using the date screen allows retro Medicaid to be authorized based on the SSI date of application and application processing time to be based on the date the DSS-8124 is signed.

6. Enter the SSI date of application beside ORIG DTE OF APPLI on the date screen. Refer to EIS 2400 for further instructions.

E. Determine Eligibility In the Retro Period

1. Evaluate eligibility using categorically needy criteria. When the individual does not meet categorically needy income and/or resources limits evaluate under any Medicaid program (Medically needy, MAF, MIC, etc.)

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL

MA-1100 AGED, BLIND AND DISABLED

SSI MEDICAID – COUNTY DSS RESPONSIBILITY

8 REISSUED 10/01/05 – CHANGE NO. 28-05 (II.E) 2. If it is an MAD application and disability has not been established for the retroactive period, follow instructions in MA-2525, Disability. This is an MAD-Y application. Send the required information to Disability Determination Services (DDS).

3. If eligible under any Medicaid coverage group in the retro period, approve the application as open/shut. Refer to EIS 4200 for instructions to authorize when eligibility is established under a Family and Children's coverage group.

4. Follow procedures in MA-2395, Corrective Actions and Responsibility For Errors, to request an override when the 365 day limit for filing claims has expired or less than 60 days remain before the time limit expires.

5. If the individual is not eligible in any Medicaid coverage group in the retro period, deny the application per MA-2304, Processing the Application.

III. COUNTY DSS RESPONSIBILITY FOR SSI APPLICANTS WHO DIE PRIOR TO DISPOSITION

This section only applies to deceased individuals who applied for SSI prior to their death.

A. Policy Rules

1. The county dss can protect the SSI date of application for retroactive Medicaid and ongoing Medicaid when an SSI applicant dies before SSA establishes eligibility for SSI.

2. The representative must request Medicaid within 60 days (90 days with good cause) from the date of the SSI disposition notice.

B. Establish Timely Application

Follow instructions in II.B. to establish the application is timely.

C. Establish the Retroactive and Ongoing Period

1. The retroactive period is 1, 2, or 3 month period prior to the SSI month of application. Verify this date on screen two of the on-line SDX.

2. The ongoing period begins with the month of SSI application and continues through the month of death.

D. Register a DSS-8124

1. Enter the exact first and last name, social security number, and birth date as listed on the SDX or SSA record. This is a new application, not a reapplication.

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL

MA-1100 AGED, BLIND AND DISABLED

SSI MEDICAID – COUNTY DSS RESPONSIBILITY

9 REISSUED 10/01/05 – CHANGE NO. 28-05 (III.D.) IMPORTANT: EIS DATA MUST MATCH SDX DATA.

2. If the deceased individual never applied for SSI, the application date entered on the DSS-8124 is the date the application is signed by the representative. Eligibility can be established no earlier than three calendar months prior to this date. Do not use the date screen when there is no SSI application date to protect.

3. When the individual applied for SSI, the SSI date of application is protected for Medicaid. Use the date screen and:

a. Place an S beside RSDI Or SSI Appeal Reversal/SSI APPL.

Note: Using the date screen allows Medicaid to be authorized based on the SSI date of application and application processing time to be based on the date the DSS-8124 is signed.

b. Enter the SSI date of application beside ORIG DTE OF APPLI on the date screen. Refer to EIS 2400 for further instructions.

E. Determine Eligibility

1. Complete a full determination of eligibility. If the individual does not qualify as categorically needy, evaluate in any Medicaid coverage group.

2. If it is an MAD application and disability has not been established, follow instructions in MA-2525, Disability, to send required information to Disability Determination Services (DDS).

3. If eligible in any Medicaid coverage group, approve the application as open/shut through the month of death. Refer to EIS 4200 to authorize assistance when eligibility is established in a Family and Children's coverage group.

4. Follow procedures in MA-2395, Corrective Action and Responsibility for Errors, to request an override when the 365 day limit for filing claims has expired or less than 45 days remain before the time limit expires.

5. If the individual is not eligible in any coverage group, deny the application per MA-2304, Processing The Application.

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL

MA-1100 AGED, BLIND AND DISABLED

SSI MEDICAID – COUNTY DSS RESPONSIBILITY

10 REISSUED 10/01/05 – CHANGE NO. 28-05

IV. COUNTY DSS RESPONSIBILITY WHEN AN SSI RECIPIENT ENTERS LONG TERM CARE (LTC)

When an ongoing SSI recipient enters long term care (or psychiatric residential treatment facility (PRTF) if under 21), SSA continues to determine Medicaid eligibility. However, the recipient or his representative must contact the county dss and request payment for nursing home cost of care. Payment for nursing home cost of care is not an automatic benefit for SSI Medicaid recipients. In order to establish eligibility for cost of care, the county dss must consider the following:

• County of residence • Patient Monthly Liability (PML) • Level of Care (FL-2/MR-2) – Not applicable to PRTF (Refer to MA-2270, Long Term Care Need And Budgeting) • Transfer of Resources – Not applicable to PRTF as transfer of resources sanctions apply only to nursing facility expenses, CAP waiver program, and in-home health services and supplies. See MA-2240, Transfer of Resources, for the definition of in-home health services and supplies. • Community Spouse and dependents income allowance • Community Spouse Resource Protection

Inpatient treatment in a psychiatric residential treatment facility (PRTF) is a covered service for individuals under 21. The claims are paid the same way as for a nursing facility. Admission to a PRTF is treated as an admission to a nursing facility for budgeting purposes.

Take the following steps to determine if an ongoing SSI Medicaid recipient is eligible for payment of cost of care:

A. Establish County of Residence

Refer to MA-2221, County Residence.

1. If the recipient has established residence in another county, or the SDX shows the incorrect county of residence, refer the a/r to the correct county to request cost of care.

2. If the recipient last lived in pla outside of North Carolina, the county of residence is the county where the a/r resides in the nursing facility.

3. If there is a conflict in county residency, refer to MA-2221, County Residence.

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL

MA-1100 AGED, BLIND AND DISABLED

SSI MEDICAID – COUNTY DSS RESPONSIBILITY

11 REVISED 11/01/11 – CHANGE NO. 17-11 (IV.) B. Establish a Case Record

When county residency has been established prepare a county case record. Include in the record all forms and documents identified in this section.

C. Establish Level of Care. (Refer to MA-2270, Long Term Care Need and Budgeting.)- Not applicable to PRTFs.

1. Request a completed FL-2/MR-2. Use the MR-2 to request the level of care for ICF-MR and CAP-MR/DD.

2. Send the FL-2 to the Claims Processing Contractor Prior Approval Unit and forward the MR-2 to the Murdock Center, Specialized Services, to obtain prior approval.

3. If the recipient does not have an approved FL-2/MR-2 for the correct level of care, do not authorize payment for cost of care.

D. Complete the Adult Medicaid Applications and Supplement B - LTC Budgeting

1. It is not necessary to complete sections already verified by SSI eligibility (i.e. citizenship, age, disability, etc.).

2. Evaluate for transfer of resources.

Transfer of Assets reports are received by DMA from SSA and sent to the counties to evaluate an SSI individual for transfer of resources. SSA enters a payment status code of N04 to indicate excess resources, but not necessarily due to a transfer. Additional investigation may be necessary to ensure it was not a transfer that created a period of ineligibility. React to reports upon receipt. Refer to MA- 2240, Transfer of Resources.

a. If a non-allowable transfer has occurred, follow transfer of resources policy. Assign sanction, if appropriate.

b. Do not authorize cost of care during sanction period.

3. If the recipient has a community spouse, determine spousal and dependent family member allowance.

4. Establish that reserve is within allowable limits. If countable assets exceed the reserve limit for one and cannot be reduced by the burial exclusion, do not authorize cost of care. (If resources have not been reported to SSA, use the DMA- 5049, Referral to Local Social Security Office, to advise SSA.)

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL

MA-1100 AGED, BLIND AND DISABLED

SSI MEDICAID – COUNTY DSS RESPONSIBILITY

12 REISSUED 11/01/11 – CHANGE NO. 17-11 (IV.D.) 5. Determine PML per MA-2270, Long Term Care Need and Budgeting.

a. The PML is “0” for the month of entry.

b. Do not count the SSI payment when determining the PML.

E. Individual Ineligible for Cost of Care

If the individual is ineligible for payment of cost of care due to inappropriate level of care, transfer of assets sanction, or excess reserve, send a DSS-8109/DSS-8109S, Notice of Benefits Denied or Withdrawn, to deny payment for cost of care.

F. Individual Eligible for Cost of Care

When it is established the recipient is eligible for payment of cost of care, take the following steps:

1. Update the following fields in EIS: a. County Number b. District # and Worker # c. Address d. Maintenance Allowance e. Earned Income, Unearned income, Total Countable Income f. PML g. Medicaid Effective Date h. Living Arrangement Code

2. Complete and send the DMA-5016, Notification of Eligibility for Medicaid/Amount and Effective Date of Patient's Liability, to the facility. Ensure the PML reported to the facility agrees with the PML in EIS.

3. Send a DSS-8110/DSS-8110S, Notice of Change in Benefits, to notify the recipient he is eligible for payment of cost of care. Also use the DSS-8110/DSS- 8110S, Notice of Change in Benefits, to:

a. Advise him that if his SSI terminates, his cost of care will also terminate.

b. Instruct him to notify the dss of any change in living arrangement or if his SSI terminates.

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL

MA-1100 AGED, BLIND AND DISABLED

SSI MEDICAID – COUNTY DSS RESPONSIBILITY

13 REVISED 10/01/05 – CHANGE NO. 28-05 (IV.) G. Review

As long as the recipient continues to receive SSI, the county dss does not have to redetermine eligibility. If the dss learns of a change that might affect eligibility for cost of care or the PML, treat as a change in situation. If the change affects eligibility for SSI, use the DMA-5049, Referral to Local Social Security Office, to report the information to SSA. Examples of when the dss must react to an SSI recipient in LTC: individual leaves the facility, changes level of care, COLA increase, change in income other than SSI, or a countable asset is discovered that was not previously considered.

H. SSI Recipient in LTC Returns to PLA

If an SSI recipient leaves LTC and returns to a private living arrangement, change the living arrangement code in EIS to reflect pla living arrangement. EIS will use the county and address on the SDX.

I. SSI Recipient in LTC Transfers to Domiciliary Facility

If an SSI recipient in LTC transfers to a domiciliary care facility, refer to the Special Assistance Manual to authorize the SA payment.

V. COUNTY DSS RESPONSIBILITY WHEN SSI TERMINATES FOR INDIVIDUALS IN LTC

When SSI terminates due to the recipient entering long term care, the county dss will often have established eligibility for LTC before the SSI payment terminates according to procedures in IV. above. In that case follow procedures in V.A., below. If eligibility for LTC has not been established, follow procedures in V.B., below.

A. SSI Terminates - Eligibility for LTC Already Established

Take the following steps if the procedures in IV. above have been followed and LTC eligibility has been previously established within the past 6 months:

1. Contact the recipient or representative to determine whether there has been a change in income or assets. If there has been a change, reverify. Also verify status of the homesite and explain estate recovery provisions.

2. Review the Adult Medicaid Applications. The recipient or the representative does not have to sign the application form.

3. Begin the "ex parte" redetermination according to procedures in MA-1000, VII, SSI Medicaid-Automated Process.

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL

MA-1100 AGED, BLIND AND DISABLED

SSI MEDICAID – COUNTY DSS RESPONSIBILITY

14 REISSUED 10/01/05 – CHANGE NO. 28-05 (V.A.) 4. If the individual remains eligible:

a. The certification period begins the current processing month in EIS.

Example: Review completed September 27. The ongoing EIS month is November. The certification period is November 1 through April 30.

b. Adjust the PML if necessary.

5. Follow EIS instructions to post eligibility.

6. If there has been a change which makes the recipient ineligible, terminate the case.

B. SSI Terminates - Eligibility for LTC Not Established

There may be some situations in which the county does not know a recipient has entered LTC until the "ex parte" redetermination has begun.

If eligibility for payment of cost of care has never been established,

1. Follow procedures in MA-2230, Financial Resources, MA-2231, Community Spouse Resource Protection, MA-2240, Transfer of Resources, and MA-2270, Long Term Care Need and Budgeting, to establish financial eligibility for cost of care and patient liability.

2. Until it is determined that the recipient is eligible for nursing home cost of care and a PML is established the recipient may receive Medicaid continuation for PLA only (according to MA-1000, VII, SSI Medicaid-Automated Process.)

3. If the recipient is eligible for cost of care follow EIS instructions to post eligibility.

4. If the recipient is eligible for Medicaid but ineligible for nursing home cost of care for any reason, follow policy in MA-2270, Long Term Care Need and Budgeting, for PLA budgeting procedures.

VI. COMMUNITY ALTERNATIVES PROGRAM (CAP

A. SSI Medicaid recipients are eligible for services offered under the Community Alternatives Programs. SSA continues to determine Medicaid eligibility. However, the county dss is responsible for establishing eligibility for CAP. County responsibilities include:

1. Level of Care (FL-2/MR-2) in the record,

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL

MA-1100 AGED, BLIND AND DISABLED

SSI MEDICAID – COUNTY DSS RESPONSIBILITY

15 REISSUED 10/01/05 – CHANGE NO. 28-05 (VI.A.) 2. Plan of Care (The county dss or CAP lead agency) in the record,

3. Complete a DMA-5008, to evaluate for transfer of resources. Refer to MA-2240, Transfer of Resources.

a. If a non-allowable transfer has occurred, follow transfer of assets policy. Assign sanction, if appropriate.

b. Do not authorize cost of care during sanction period.

4. Assess Community Spouse Resource Protection (CSRP), if applicable.

B. Continue to follow all rules and procedures in MA-2280, Community Alternatives Programs Medicaid Eligibility, to authorize CAP coverage for an individual who is already eligible for Medicaid. In addition, consider the following information for SSI recipients who are also eligible for CAP.

1. Deductible

SSI Medicaid recipients do not have a deductible under CAP.

2. EIS

a. The SDX will continue to control all elements in EIS for SSI recipients who are eligible for CAP except for the CAP indicator and effective date.

b. The county dss is responsible for:

(1) Entering in EIS the CAP indicator and effective date.

(2) Terminating CAP coverage in EIS.

3. Refer to EIS 3101 for instructions on posting CAP.

VII. IN-HOME HEALTH SERVICES AND SUPPLIES

When an ongoing SSI recipient receives assistance with in-home health services and supplies, the county dss will be notified by the recipient, provider, or Medicaid claims contractor that a transfer of resources evaluation is needed. The dss is responsible for establishing eligibility by completing a transfer of resources evaluation. Refer to MA-2240, Transfer of Resources, for procedures.

A request for a transfer of resources evaluation is considered a change in situation that must be reviewed promptly. Refer to MA-2340, Change In Situation, for procedures.

Take the following steps to determine if an ongoing SSI Medicaid recipient is eligible for in- home health services and supplies:

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL

MA-1100 AGED, BLIND AND DISABLED

SSI MEDICAID – COUNTY DSS RESPONSIBILITY

16 REISSUED 10/01/05 – CHANGE NO. 28-05 (VII.) A. Establish the County of Residence

Refer to MA-2221, County Residence.

1. If the recipient has established residence in another county, or the SDX shows the incorrect county of residence, the county dss in which the report appears must contact the county of residence immediately to advise them that a transfer of resources evaluation is needed.

Within 5 workdays, the first county must send a copy of the report to the county of residence who must complete the evaluation. The individual will remain on the first county’s report until the transfer of assets evaluation indicator has been updated even if the county of residence is changed in EIS.

2. If there is a conflict in county residency, refer to MA-2221, County Residence.

B. Establish a Case Record

Within 5 workdays of being notified of the need for the evaluation, the county of residence must contact the recipient verbally or in writing to determine if a non-allowable transfer has occurred.

In addition, send a DMA-5049, Referral to Local Social Security Office, to notify SSI of the correct county of residence.

1. If the recipient states there have been no transfers and the investigation does not prove otherwise, document the case record and update the Assets Transfer Tracking Screen to indicate that there is no transfer of resources sanction. Refer to MA-2240, Transfer of Resources, and EIS-3900, Assets Transfer Tracking Screen, for procedures.

2. If the recipient states that a non-allowable transfer has occurred, follow transfer of resources policy. Update the Assets Transfer Tracking Screen and assign sanction, if appropriate, following timely notice. Refer to MA-2240, Transfer of Resources, and EIS-3900, Assets Transfer Tracking Screen, for procedures.

3. If the recipient fails or refuses to respond to the request for information regarding transfer of resources, complete the EIS Assets Transfer Tracking Screen and impose an indefinite sanction following timely notice. Refer to MA-2240, Transfer of Resources, and EIS-3900, Assets Transfer Tracking Screen, for procedures.

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL

MA-1100 AGED, BLIND AND DISABLED

SSI MEDICAID – COUNTY DSS RESPONSIBILITY

17 REISSUED 11/01/11 - CHANGE NO. 17-11 (VII.) C. Individual Eligible for In-Home Health Services and Supplies

When it is established that the recipient is eligible for payment of in-home health services and supplies, send the recipient a manual approval notice to continue assistance with these services.

D. Individual Ineligible for In-Home Health Services and Supplies

1. If the individual is ineligible for assistance with in-home health services and supplies due to a transfer of resources sanction, send the recipient a manual DSS- 8110/DSS-8110S, Notice of Change In Benefits, to terminate assistance with these services. Refer to MA-2240, Transfer of Resources, for procedures.

2. Medicaid assistance continues for other covered services.

E. Assets Transfer Tracking Screen

When the transfer of resources evaluation is completed, update the evaluation indicator and/or sanction period in EIS. Refer to MA-2240, Transfer of Resources and EIS-3900, Assets Transfer Tracking Screen, for procedures.

VIII. EMERGENCY CERTIFICATION FOR MEDICAID

A. There may be some instances when an SSI recipient needs a Medicaid card before EIS can automatically issue a card. This may occur when:

1. A newly approved SSI recipient has not received Medicaid due to SSA lag time in updating the SDX or between receipt of SDX and processing of this data by EIS.

2. An SSI recipient recently established residency in North Carolina and is not yet on North Carolina's SDX.

3. The SDX does not verify eligibility due to a problem with the SSA system.

B. Procedures

When an individual requests emergency Medicaid:

1. Document an emergency situation exists.

a. An emergency situation exists when there is an immediate medical need that cannot be met without a current Medicaid card. For example, an individual needs heart medication and the pharmacist will not fill the prescription without a Medicaid card.

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL

MA-1100 AGED, BLIND AND DISABLED

SSI MEDICAID – COUNTY DSS RESPONSIBILITY

18 REVISED 11/01/11 – CHANGE NO. 17-11 (VIII.B.)

b. When an individual has a Medicaid card from another state, verify if the provider will accept the other state's Medicaid. If not, initiate emergency card procedures.

2. Establish SSI eligibility. SSI eligibility can be established by verifying the individual is on the SDX Exception List, on-line SDX, SOLQ, or by the emergency certification.

a. First, verify whether the individual is on the exception list because data in EIS did not match with data on the SDX. In this situation, do not issue an emergency card. Work the exception report and the card is issued automatically by EIS in the nightly cycle.

b. If the case is not on the exception list, view the on-line SDX. When the individual is on the SDX in current pay status (CO1), SSI eligibility is established.

c. Counties may use SOLQ to verify SSI for emergency Medicaid. Using SOLQ should eliminate the need most often for using the DMA-5050, Emergency Certification for Medicaid.

d. When the individual is not on the exception list, the on-line SDX, or SOLQ, the DMA-5050, Emergency Certification for Medicaid, must be completed by SSA to establish SSI eligibility and North Carolina residence.

e. The DMA-5050, Emergency Certification for Medicaid, may be initiated by DSS or SSA. The completed form:

(1) Verifies that the individual is eligible for SSI in the current month, and

(2) Verifies the individual is a North Carolina resident, and

(3) Provides all the necessary identifying information needed to issue a Medicaid card.

3. When SSI eligibility has been established via the SDX, SOLQ, or the Emergency Certification form:

a. Enter an administrative DSS-8124 (unsigned and untracked). Mark ADMINISTRATIVE.

b. Use exact Social Security number, last name, first name, and date of birth as the SSA record. This ensures the same EIS Individual ID is used when the SSI Medicaid case is created.

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL

MA-1100 AGED, BLIND AND DISABLED

SSI MEDICAID – COUNTY DSS RESPONSIBILITY

19 REISSUED 11/01/09 - CHANGE NO. 16-09 (VIII.B.3.) c. The system will set the SSI status to “N”.

d. Approve open/shut for the current month only.

e. Retain the DMA-5050, Emergency Certification for Medicaid, indefinitely.

IX. COUNTY DSS RESPONSIBILITY FOR AN SSI CHILD IN HSF

A. SSI Child Receiving in HSF

1. A child who receives SSI can be in HSF. This allows the county dss to continue to update certain data elements in EIS. This is necessary because children in dss custody may have an address and county number on the SDX other than the Medicaid county of residence. Also, this allows the State to identify children in dss custody for federal reporting purposes.

2. The county dss updates all fields in EIS except the following:

a. Certification Period b. RSDI Claim Number c. First Name, Middle Initial, Last Name d. SSN e. Date of Birth f. Sex

NOTE: When there is a conflict between SSA records and dss records for one of the above elements and it causes a problem, use the DMA-5049, Referral to Local Social Security Office to report the conflict. For example, an error in the date of birth or name may cause claims to deny.

3. When the SSI status is "Y" in an HSF case, Medicaid cannot be terminated by the county dss.

4. The county dss continues to have placement responsibility for the SSI child.

B. SSI Child in HSF is No Longer in County Custody

1. When an SSI child who is in HSF is no longer in county custody, he must be taken out of HSF.

2. As long as he receives SSI his Medicaid cannot be terminated.

3. Enter a DSS-8125 to transfer the HSF case to MAABD. Refer to EIS 4200 for instructions.

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL

MA-1100 AGED, BLIND AND DISABLED

SSI MEDICAID – COUNTY DSS RESPONSIBILITY

20 REVISED 11/01/09 - CHANGE NO. 16-09 (IX.) C. SSI Medicaid Child Enters County Custody

1. When an SSI recipient who is receiving Medicaid under MAABD enters county custody, the county dss can transfer the child to HSF.

2. Enter a DSS-8125 to transfer the MAABD case to HSF. Refer to EIS 4200 for instructions.

X. NON-ELIGIBILITY RELATED MEDICAID PROCEDURES

A. Returned Cards

1. Undeliverable Medicaid cards will be returned to the county dss. It is recommended that the cards be filed in one place. If a recipient reports he did not receive his Medicaid card, research the file. The card can be given to him personally or mailed to him. Follow instructions in MA-2380, Medicaid Identification Card.

2. Advise the recipient that Medicaid cards are not forwarded. Instruct the individual to report any change in address to SSA to ensure the Medicaid address is corrected.

3. Retain returned ID cards for 3 months. If they have not been claimed they may be shredded. Refer to shredding instructions in MA-2380, Medicaid Identification Card.

B. Replacement Cards

If an SSI Medicaid recipient reports he lost his Medicaid card or did not receive it, the county dss can order a replacement Medicaid card. Follow procedures in MA-2380, Medicaid Identification Card, to issue the card.

C. Transportation Services

SSI Medicaid recipients are eligible for Medicaid transportation services. The Medicaid approval notice instructs the SSI recipient to contact the county dss if he needs transportation to medical care.

An SSI recipient may apply for transportation in person or by phone. When an SSI Medicaid recipient requests transportation assistance, follow instructions in MA-2910, Medicaid Transportation.

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL

MA-1100 AGED, BLIND AND DISABLED

SSI MEDICAID – COUNTY DSS RESPONSIBILITY

21 REVISED 11/01/11 – CHANGE NO. 17-11 (X.) D. Community Care of North Carolina/Carolina Access (CCNC/CA)

SSI Medicaid recipients are required to participate in Community Care of North Carolina/Carolina Access (CCNC/CA) unless they also receive Medicare. CCNC/CA participation is optional for Medicare beneficiaries.

1. New SSI Medicaid recipients will have an exempt code automatically assigned by EIS. These exempt codes will be:

a. 9900010 for SSI Medicaid recipients who are required to participate in the program, or

b. 9900011 for SSI Medicaid recipients who have Medicare and for whom participation is optional.

2. The SSI Medicaid approval notice gives a brief explanation of CCNC/CA and instructions to contact the county dss within 30 days to choose a primary care provider.

3. When the recipient contacts the dss by phone or in person, an Income Maintenance Caseworker is responsible for providing program education and a list of participating primary care providers from which to make a choice. The State CCNC/CA office provides educational materials for the counties to use.

4. When a mandatory recipient does not contact the dss within 30 days, the county assigns a primary care provider. The dss will notify each individual by letter of his provider and to explain the program and the correct way to access medical care. It is extremely critical that dss educate SSI recipients about the proper use of program policies and procedures.

5. In order to identify and track SSI Medicaid recipients, an SSI EXEMPT Report (for exempt codes 9900010 & 9900011) is generated monthly and mailed to each CCNC/CA county. Refer to EIS 4200 for additional information on the report.

6. It is strongly recommended that each Community Care of North Carolina/Carolina Access county maintain a list of mandatory SSI Medicaid participants in Community Care of North Carolina/Carolina Access. Document on the list:

a. That a duplicate Medicaid card was ordered following a request.

b. Any request for change of primary care provider by the recipient and date this request is made.

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL

MA-1100 AGED, BLIND AND DISABLED

SSI MEDICAID – COUNTY DSS RESPONSIBILITY

22 REVISED 11/01/11 – CHANGE NO. 17-11 (X.D.6.) c. Any request by the primary care provider that a patient be disenrolled with that practice.

If there are any questions about Community Care of North Carolina/Carolina Access (CCNC/CA), please call your Medicaid Program Representative.

E. IV-D Referral

1. Caretakers of SSI children must cooperate with IV-D to establish medical support agreements when the following applies:

a. The caretaker is applying for or receiving Medicaid for herself in any aid program/category except MPW (see MA-2375, Procedures for Child Support Enforcement), and

b. The child meets the criteria listed in MA-2375, Procedures for Child Support Enforcement.

2. Caretakers of SSI children who are not applying for or receiving Medicaid for themselves may choose to cooperate with Child Support. The approval notice for SSI Medicaid instructs the recipient to contact IV-D if there is a child lacking parental support due to absence of one or both parents.

3. EIS will notify IV-D of the new SSI Medicaid case when a child lacking parental support due to absence of one or both parents:

a. Is approved for SSI Medicaid, and

b. Previously had an automated referral to IV-D completed. This continues the link between IV-D and EIS which allows automatic updates between the two systems.

4. Individuals in a pending application or active case in EIS who are already referred to IV-D when approved for SSI may continue to use IV-D services. EIS will continue to send automatic updates to IV-D for these cases if the SSI Medicaid case is created with the same EIS Individual ID. New SSI Medicaid approvals, including individuals who have never been active in EIS, may also use IV-D services.

North Carolina Department of Health and Human Services Division of Medical Assistance Medicaid Eligibility Unit AGED, BLIND AND DISABLED MEDICAID MANUAL MA-2000

NON-SSI ELIGIBILITY REGULATIONS

1 MA-2000 NON-SSI ELIGIBILITY REGULATIONS REVISED 08/01/13 – CHANGE NO. 05-13

I. INTRODUCTION TO NON-SSI MEDICAID ELIGIBILITY DETERMINED BY DSS

In addition to Medicaid for SSI beneficiaries, North Carolina provides Medicaid to needy aged, blind, and disabled individuals who do not receive SSI. For these individuals, eligibility is determined by the county department of social services. Each individual must meet categorical, financial, and non-financial requirements of an aid/program category in order to be eligible for Medicaid.

Use the 2000 Series to determine Medicaid eligibility for all non-SSI beneficiaries.

The purpose of this section is to list the categorical, financial, and non-financial Medicaid requirements for aged, blind, and disabled individuals who do not receive SSI, and to provide a brief overview of the individuals covered under adult Medicaid by classification.

II. CATEGORICAL REQUIREMENTS FOR NON-SSI MEDICAID COVERAGE GROUPS

A. MAA

To receive under MAA the individual must be aged 65 or older.

B. MAB

To receive under MAB the individual must be legally blind according to the SSI definition of disability. Blindness is defined as central visual acuity of 20/200 or less in the better eye with the use of a correcting lens or a limitation in the field of vision of the better eye that meets certain criteria. (Also evaluate for HCWD. See MA 2180.)

C. MAD

To receive under MAD an individual must:

1. Be disabled according to the SSI definition of disability. The SSI definition of disability is: A physical or mental impairment which prevents an individual from engaging in any substantial gainful activity (or for a child under 18, an impairment of comparable severity) and which has lasted or is expected to last for at least 12 months or is expected to result in death. (For HCWD, substantial gainful activity is not a consideration. See MA 2180.)

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL MA-2000

NON-SSI ELIGIBILITY REGULATIONS

2 REVISED 08/01/13 - CHANGE NO. 05-13 (II.C.)

2. Be under age 65.

D. MQB-Q

To receive under MQB-Q an individual must be enrolled in Medicare (Part A and/or B).

E. MQB-B

To be eligible under MQB-B an individual must be enrolled in Medicare Part A.

F. MQB-E

To be eligible under MQB-E an individual must be enrolled in Medicare Part A.

G. M-WD

To be eligible under MWD an individual must have lost entitlement to Medicare Part A solely due to earnings in excess of the Substantial Gainful Activity threshold as determined by SSA.

III. NON-FINANCIAL REQUIREMENTS APPLICABLE TO ADULT MEDICAID COVERAGE GROUPS

A. Be a citizen of the U.S. or a “qualified alien” as defined in MA-2506, US Citizenship Requirements or MA-2504, Alien Requirements.

Non-qualified aliens defined in MA-2504 are potentially eligible to receive Medicaid for emergency medical treatment only, including labor and delivery.

Determine alien status and the scope of Medicaid coverage the alien is permitted to receive as defined in MA-2504, Alien Requirements.

B. Be a resident of North Carolina. Refer to MA-2220, State Residence.

C. Not be receiving Medicaid for his own needs from another aid program/category, county, or state.

D. Not be an inmate of a public institution unless incarcerated in a North Carolina Department of Public Safety, Division of Prisons (DOP) facility (see MA-2510/MA-3360, Living Arrangement for instructions on suspending the eligibility of DOP inmates).

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL MA-2000

NON-SSI ELIGIBILITY REGULATIONS

3

REISSUED 03/01/14 - CHANGE NO. 01-14 (III.)

E. Not be in an institution for mental disease with more than 16 beds except individuals age 65 or older or individuals under age 21 receiving inpatient psychiatric services (see MA-2510/MA-3360, Living Arrangement).

F. Provide verification of all health insurance coverage for eligible assistance unit members and assign to the state all rights to third party payments from such insurance coverage.

G. Furnish his Social Security number, or apply for a number if he does not already have one, and furnish all Social Security numbers which he has used or under which he has received benefits.

H. Cooperate with the local child support enforcement (IV-D) agency in establishing paternity and securing medical and child support for any deprived child for whom the individual is caretaker when assistance is requested for that child. Refer to MA-2375, Procedures for Child Support Enforcement.

I. Apply for all benefits to which he may be entitled.

IV. FINANCIAL REQUIREMENTS APPLICABLE TO ADULT MEDICAID COVERAGE GROUPS

A. Resources

Not have countable assets that exceed the individual or couple resource limit for the classification and program in which eligibility is determined. See MA- 2260, Financial Eligibility Requirements-PLA and MA-2230, Financial Resources.

B. Income

Be in financial need according to the income limits for the program in which eligibility is determined. See MA-2260, Financial Eligibility Requirements- PLA and MA-2250, Income.

C. Transfer of Assets

For Long Term Care, PACE, and CAP cases not have transferred (or established a trust) real or personal property, including liquid resources, as specified by MA-2240, Transfer of Resources.

North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL MA-2000

NON-SSI ELIGIBILITY REGULATIONS

REVISED 03/01/14 - CHANGE NO. 01-14

V. NON-SSI AGED, BLIND, AND DISABLED COVERAGE GROUPS BY CLASSIFICATION

A. Categorically Needy - No Money Payment (Refer to MA-2100, Categorically Needy - No Money Payment, MA-2110, Passalong), and MA-2180, Health Coverage for Workers with Disabilities.

1. Individuals with income below 100% of the Federal Poverty Level and resources below the SSI limit who do not receive SSI.

2. Individuals Deemed To Be Receiving SSI (Passalongs).

3. Individuals covered under HCWD with unearned income less than or equal to 150% of Federal Poverty Level (there is no limit on total countable income for this program).

B. Medically Needy (Refer to MA-2120, Medically Needy Regulations)

Individuals who meet the non-financial eligibility requirements who have income/resources that exceed categorically needy income limits.

C. Medicare-Aid Coverage Groups

Medicare-Aid is a limited Medicaid program that supplements Medicare coverage for low income individuals.

1. Qualified Medicare Beneficiaries (MQB-Q) - Refer to MA-2130, Qualified Medicare Beneficiaries – Q.

2. Specified Low Income Medicare Beneficiaries (MQB-B) - Refer to MA-2140, Qualified Medicare Beneficiaries – B.

3. Qualified Disabled Working Individuals (MWD) - Refer to MA-2150, Medicaid Working Disabled.

4. Qualifying Individuals - QI-1’s (MQB-E) - Refer to MA-2160, Qualified Individuals 1 (MQB-E).

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North Carolina Department Of Health and Human Services Division of Medical Assistance Medicaid Eligibility Unit AGED, BLIND AND DISABLED MEDICAID MANUAL MA-2100 CATEGORICALLY NEEDY - NO MONEY PAYMENT 1 MA-2100 CATEGORICALLY NEEDY-NO MONEY PAYMENT REVISED 03/01/14-CHANGE NO. 01-14

I. INTRODUCTION TO CATEGORICALLY NEEDY - NO MONEY PAYMENT (N)

Categorically Needy - No Money Payment is a Medicaid classification for aged, blind, and disabled individuals who do not receive SSI, but whose resources are below the categorically needy levels and whose income is below 100% of the Federal Poverty Level (FPL). This section defines the general requirements to determine eligibility as categorically needy for non- SSI recipients. (For working disabled or blind individuals, see MA 2180, Health Coverage for Workers with Disabilities.)

Always evaluate aged, blind and disabled individuals as categorically needy before evaluating under medically needy criteria.

II. POLICY RULES FOR CATEGORICALLY NEEDY

A. Meet the eligibility requirements in MA-2000, Non-SSI Eligibility Regulations.

B. Categorically Needy Income Limits (Refer to MA-2260, Financial Eligibility Regulations - PLA.

C. Not exceed the resource limit (Refer to MA-2260, Financial Eligibility Regulations – PLA.

D. Classification

1. Non-HCWD categorically needy individuals have classification “N” or “Q”, if dually eligible.

2. HCWD categorically needy individuals have classification “N” or “G” or, if dually eligible, “”Q” or “B.”

E. Deductible

Individuals evaluated as categorically needy cannot have a deductible. When income exceeds the categorically needy income limit, evaluate as medically needy.

F. Certification/Authorization

Refer to MA-2350, Certification and Authorization.

G. Buy-In

For categorically needy cases, the buy-in effective date is the first day of the first month the recipient is authorized for Medicaid.

Refer to MA-2410, Medicare Enrollment and Buy-In, for procedures.

North Carolina Department of Health and Human Services North Carolina Medicaid Division of Health Benefits AGED, BLIND AND DISABLED MEDICAID MANUAL MA-2110

PASS-ALONG ____ REVISED 01/5/2026 – CHANGE NO. 01-26 I. INTRODUCTION TO PASS-ALONG To preserve Medicaid coverage for certain groups of individuals who lose Supplemental Security Income (SSI) and/or Special Assistance (SA), Congress enacted special Medicaid eligibility provisions. These provisions require the State to continue to evaluate specified groups of former SSI and SA beneficiaries under categorically needy criteria. Qualified individuals are eligible for a disregard of certain Retirement, Survivors, and Disability Insurance (RSDI) benefits. This is called Pass-along. Pass-along only applies to Private Living Arrangement (PLA) budgeting and to Step I of Long-Term Care (LTC) budgeting.

A. Four Eligibility Groups for Pass-along

1. There are four eligibility groups for Pass-along:

a. Cost of Living Allowance (COLA)/Pickle Amendment Group

b. Disabled Adult Children (DAC)

c. Early Widow(er)

d. Disabled Widow(er)

2. A former State/County Special Assistance beneficiary may also qualify for Pass-along in any of these four groups as long as the individual continues to reside in an Adult Care Home (ACH), even if they never received SSI.

B. Pass-along Eligibility

1. An applicant/beneficiary (a/b) need not claim Pass-along status. Many may not be able to remember when or if they received SSI or SA.

2. Fully investigate Pass-along eligibility in every case where the a/b is otherwise over income for Categorically Needy Medicaid Aged, Blind, Disabled (CN MAABD) because of income from Social Security.

3. Once an a/b is determined to be Pass-along eligible in one of the four groups, always consider the a/b as Pass-along in subsequent recertifications and applications unless one of the eligibility requirements for that Pass-along group changes.

C. Evaluating for Pass-along When determining Pass-along eligibility, NC FAST will systematically screen for eligibility in all applicable Pass-along groups.

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1. An a/b receiving Social Security as Widow(er)s or as Disabled Adult Children, are evaluated under Disabled Adult Children (DAC), Early Widow(er)s, or Disabled Widow(er)s (as applicable) before evaluation under COLA/ Pickle Amendment Group.

2. The caseworker must document whether or not the individual is Pass-along eligible, the SSI/SA termination date and resources used to verify Pass-along status in NC FAST.

3. Maintain a copy of the following completed forms:

a. DHB-5150A Pass-along Screening Guide This form is completed when evaluating Pass-along groups of former Supplemental Security Income (SSI) and Special Assistance (SA) beneficiaries under categorically needy (C/N) criteria.

b. DHB-5150B Screening Guide for Medicaid Eligibility under the COLA Pass-along This form is completed when determining if an a/b qualifies for COLA Pass- along status under the Pickle Amendment.

II. COLA PASS-ALONG/ PICKLE AMENDMENT GROUP

A. Eligibility Requirements 1. Currently receives RSDI (Social Security) benefits;

2. Was eligible for and received RSDI and either SSI or State/County SA concurrently for at least one month after April 1, 1977 (or is treated as having received them concurrently under II.A.4. below); and

3. Lost SSI or SA benefits for any reason but would currently be eligible if the total amount of all COLA increases, since losing SSI or SA benefits, were excluded from countable income.

4. An a/b who received SSI and then were found retroactively eligible for RSDI are considered to have received SSI and RSDI concurrently.

5. If Pass-along eligibility is based on prior receipt of SA (not SSI), the a/b must currently reside in an adult care home.

B. Verify and Document an Applicant/Beneficiary (A/B) Who Lost SSI or SA Eligibility 1. If an a/b is in assisted living/adult care home (ACH) the caseworker must:

a. Check all available sources including NC FAST case records and

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b. Determine if the a/b has received Special Assistance currently or in the past.

2. Use the following resources to identify if an a/b lost SSI or SA eligibility.

a. STATE DATA EXCHANGE (SDX)

1. The Medicaid Eligibility Code field indicates the eligibility status. 2. If the code is R, D, or W, the individual is ineligible for an SSI payment. Refer to NC FAST Help job aid, Requesting and Viewing Online Data (OVS) to request SDX information in NC FAST.

Note: SDX will not show SSI terminations prior to 01-01-95. If an SSI termination may have occurred prior to that date, contact the local Social Security Administration (SSA) office.

b. COLA Reports

1. Cola Reports are available in NC FAST Help and updated annually.

2. Review of COLA Pass-along eligibility based on these reports is required.

3. The reports are leads and may not identify all Pass-along eligible individuals.

4. SSI may have been terminated for a reason other than the COLA, but the individual may still be Pass-along eligible. Such persons will not appear on these reports.

5. Refer to MA-2940/ MA-3570, Social Security and Cost-of-Living Adjustment (COLA).

c. SSI Termination/Alert Report and Ex-parte Review for SSI Termination Tasks

1. SSI Reports and Tasks are available in NC FAST.

2. It is the responsibility of the county to monitor termination of SSI benefits and evaluate individuals for all Medicaid programs.

3. Refer to MA-1000, SSI Medicaid – Automated Process

4. Refer to in NC FAST Help. Job aid, SDX Overview, Tasks, and Work Queues.

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C. Verify and Document the Following Factors for Potential COLA Pass-along Eligibility 1. The applicant/beneficiary (a/b) statement.

2. The date SSI or SA benefits were terminated on or after April 1977.

3. The current amount of the applicant’s/beneficiary’s RSDI. 4. The amounts of all RSDI COLA increases the a/b received since SSI or SA was terminated.

5. If the a/b lost SSI due to receiving RSDI:

a. Use the factor found in the Pickle Amendment chart below.

b. Find the year in which the individual lost SSI and multiply the factor by the current RSDI amount.

c. Compare the result to the current SSI Federal Benefit Rate (FBR) to determine eligibility.

6. If the a/b lost SA due to RSDI benefit increase:

a. Use the factor found in the Pickle Amendment chart below. Find the year in which the individual lost SA and multiply the factor by the current RSDI amount.

b. Compare the result to the current Special Assistance (SA) income standard to determine Medicaid eligibility. Beneficiary must reside in an ACH to be eligible.

Reference Special Assistance policy regarding income standards.

7. When an a/b’s RSDI increase caused them to

a. Lose SSI and become ineligible for Medicaid using Pass-along eligibility rules, and

b. The a/b is later determined to be eligible for SA and

c. The same a/b later loses SA benefits due to an RSDI increase,

the caseworker must determine which Pass-along group criteria should be used to evaluate for Pass-along eligibility and document the case record.

Example: The caseworker is completing a review for an a/b currently residing in an ACH. The a/b receives RSDI, and the most recent COLA increase resulted in the

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a/b losing eligibility for SA. Prior to residing in the ACH, the a/b received SSI and RSDI for at least one concurrent month. The caseworker must establish eligibility/ineligibility for Pass-along for both dates.

Lost SSI: 2015 • The caseworker multiplies the a/b’s current RSDI by the 2015 factor in the chart below, however the resulting amount exceeds the current SSI income standard, therefore the a/b is not eligible for Medicaid due to Pass-along for losing SSI. Lost SA: 2021

• The caseworker multiplies the a/b’s current RSDI by the 2021 factor in the chart below. If the resulting amount is below the current SA income standard, the a/b remains eligible for Medicaid because they continue to live in an ACH. Note: Contact the local Social Security Administration (SSA) Office when unable to verify benefits using BENDEX, SDX, SOLQ, case record or SSA Benefit Verification letter.

D. When the A/B is determined COLA Pass-along eligible: 1. Disregard any COLA increases received after SSI or SA was terminated for any reason from the current RSDI income for the a/b.

2. If there is a financially responsible person (spouse or parent) who receives RSDI benefits, also disregard all COLA increases received by that person since the a/b was terminated from SSI or SA.

3. The result is the countable RSDI income. 4. Refer to the current Pickle Amendment Chart below for assistance in deducting all RSDI COLA increases received by the a/b and/or financially responsible person since the last month in which the a/b was eligible for both RSDI and SSI or RSDI and SA concurrently.

E. Determine Countable Income Add the countable RSDI Income to other countable earned and unearned income then compare it to the current SSI or SA income limit. (Use the 1/3 reduced income limit if appropriate. Refer to MA-2261 1/3 Reduction)

1. If the countable income is below the current SSI or SA income limit, continue to evaluate as categorically needy.

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The SA level of care the person was in when they lost their SA will determine the maintenance amount for Medicaid Pass-along (SA Basic or Special Care Unit (SCU))

2. If the countable income is above the current SSI or SA income limit, the individual is not eligible for COLA Pass-along.

a. DO NOT disregard COLA. This person is ineligible under COLA Pass-along. b. If ineligible for COLA Pass-along, 1. Count the a/b and financially responsible person’s current RSDI income

2. Document in NC Fast and

3. Send the appropriate notice(s).

EXAMPLE : (COLA Pass-along) Applicant/Beneficiary (a/b), age 55, lives alone in their own home with countable assets less than $2,000. The a/b receives countable RSDI benefits in the amount of $1480 ($1,500 minus $20 disregard) a month which is over the Categorically Needy income limit for Medicaid.

A/B was informed by local agency that they have a large Medicaid deductible they must meet prior to Medicaid authorization.

A/B applied for RSDI and SSI in October 1985, alleging disability beginning October 1984 and was approved for disability in October 1986, as of the alleged onset date. A/B was initially paid SSI for October 1985 through December 1986 under SSA normal procedures (in order to provide Medicaid eligibility).

A/B received their first RSDI check in December 1986, which caused SSI to terminate at the end of December 1986. They also received retroactive RSDI benefits during the same time period which were reduced by the amount of SSI received. The regular RSDI monthly payment exceeded the income limit for SSI.

Disregard RSDI COLA increases since the 1986 SSI termination.

$ 1500 (a/b’s RSDI) x 0.338 (use the year 1986 percentage from Pickle Chart below) $507 (round up) - $20 (disregard) $487 (under the 2026 SSI income limit)

The a/b is Medicaid eligible based on COLA Pass-along (but not SSI eligible).

EXAMPLE: (COLA Pass-along couple) An applicant lives at home with their 75- year-old spouse who receives RSDI retirement of $1100/month. The spouse has never received SSI.

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The applicant is age 70 and receives $785/month in RSDI benefits. (Both figures include Medicare premiums). Their countable joint income of $1865 ($1885 minus $20 disregard) is over the MAA categorically needy income limit for couples.

The applicant received both RSDI and SSI concurrently until 1991 when the couple got married. This caused the applicant to be ineligible for SSI beginning in 1991 based on their combined income.

Disregard the couple’s COLA increases since the applicants SSI terminated.

$1100 (spouse RSDI - including Medicare premiums) + $785 (applicant RSDI - including Medicare premiums) $1885 x 0.409 (use the year 1991 percentage from chart in II. F. below) $771 (round up)

- $20 (disregard)

$751 (under the 2026 SSI couple income limit)

The applicant, but not the spouse, is eligible for Medicaid under the COLA Pass- along because the applicant received SSI. The spouse has never received SSI.

EXAMPLE: (COLA Pass-along couple; both prior SSI) A married couple (Beneficiary1 and Beneficiary2) live together in their home and have total assets of less than $3,000. Both beneficiaries’ SSI have terminated. Beneficiary1 is 39 years old, and SSI terminated on 12/2013. They began receiving $1,130/month in RSDI on 12/2013.

50-year-old Beneficiary2 currently receives $50/month in private pension and began receiving Social Security Disability payments of $946 as of 1/2006. Beneficiary2 SSI terminated on 12/2005.

Beneficiary 1 Beneficiary 2 $1,130 (RSDI) $946 (disability payment) x .715 (use the year 2013 percentage from chart in II. F. below) x .583 (use the 2005 percentage from chart in II. F. below) $808 (round up) $552 (round up) -$20 (disregard) + 50 (private pension) $788 - $20 (disregard) $582

B1 Total Countable Income

$788 B2 Total Countable Income +$582 Married Couple’s Total Countable Income $1,370

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Disregard couple’s total increases since SSI terminated. The total countable income is under the 2026 SSI couple’s income limit. Beneficiary1 and Beneficiary2 are eligible under Cola Pass-along.

Reduction Factors for Calculating Medicaid Eligibility Under the Pickle Amendment During 2026 If the last month in which a person received SSI while, or immediately prior to, receiving RSDI was in any of the periods in the chart below, multiply the present amount of their RSDI by the corresponding factor in the chart below, to obtain the current countable COLA Pass-along income.

Compare the current countable COLA Pass-along income to the SSI Federal Benefit Rate (FBR). If it is below FBR the a/b may be eligible for COLA Pass-along. Refer to MA-2940, Social Security and Cost-of-Living Adjustment (COLA).

Pickle Amendment Chart (2026) (If SSI terminated, Multiply 2026 RSDI income by:)

*OASDI (Old-Age, Survivors, and Disability Insurance) also known as RSDI.

F. Recertifications At subsequent recertifications, determine if the individual still qualifies as Pass-along. Evaluate the income of the beneficiary. If countable income after deducting COLA results in ineligibility for SSI or SA, the individual is no longer eligible as COLA Pass-along. Evaluate under other Pass-along groups and all Medicaid programs.

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III. DISABLED ADULT CHILD (DAC) PASS-ALONG

A. Eligibility Requirements 1. Currently entitled to and receives RSDI benefits as a DAC on a parent’s record due to the retirement, death, or disability of a parent; 2. Has blindness or a disability which began before age 22 (RSDI benefits did not have to begin prior to age 22);

3. Lost SSI or SA due to receipt of or increases in the RSDI benefit; and

4. Would currently be eligible for SSI or SA if you disregard the current RSDI benefit.

5. If DAC Pass-along eligibility is based on former receipt of SA (not SSI), the individual must currently reside in an adult care home.

B. Identify Individuals Who Lost SSI or SA Eligibility Due to Receipt of DAC RSDI Benefits. Applicants/beneficiaries need not claim Pass-along status. Many individuals may not be able to remember when or if they received SSI or SA.

1. Fully investigate Pass-along eligibility in every case where the individual is otherwise over income for Categorically Needy-Medicaid Disabled (CN MAD) because of income from Social Security.

2. Use the following resources to identify individuals who lost SSI or SA eligibility:

a. SDX - The Medicaid Eligibility Code field indicates an eligibility status code of “D” for a Disabled Adult Child.

i. Refer to NC FAST Help job aid, Requesting and Viewing Online Data (OVS) to request SDX information in NC FAST.

ii. SDX will not show SSI terminations prior to 01-01-95. If an SSI termination may have occurred prior to that date, contact SSA. b. SSI Termination/Alert Report and Ex-Parte Review for SSI Termination tasks are available in NC FAST.

i. It is the responsibility of the county to monitor termination of SSI benefits and evaluate individuals for all Medicaid programs.

ii. Refer to MA-1000, SSI Medicaid – Automated Process

iii. Refer to NC FAST Help job aid, SDX Overview, Tasks, and Work Queues.

c. For individuals receiving RSDI DAC benefits who may have lost SSI prior

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to January 1, 1995, verify through the case record or the local Social Security Office.

The Social Security Claim Number suffix is “C” if the a/b receives as a disabled adult child. However, children other than DAC’s can also have a “C” suffix.

d. Individuals in assisted living/ACH who may have been terminated from Special Assistance.

C. Verify DAC Pass-along Eligibility Factors. 1. The date SSI or SA benefits were terminated.

2. The current amount of the a/b’s RSDI disabled adult child benefit.

D. DAC Eligibility If the individual is DAC Pass-along Eligible Disregard all the Current RSDI Income.

E. Determine Countable Income Compare other countable earned and unearned income to the current SSI or SA income limit. (Use the 1/3 reduced income limit if appropriate. Refer to MA-2261 1/3 Reduction).

1. If the countable income does not exceed the current SSI or SA income limit, continue to evaluate as categorically needy and determine eligibility without counting RSDI. The person is eligible under DAC Pass-along.

2. If the countable income is above the current SSI or SA income limit, determine eligibility counting RSDI benefits.

a. DO NOT disregard the RSDI income. This person is ineligible under DAC Pass-along.

b. If ineligible, count the current RSDI income and document in NC Fast.

c. Evaluate for all Pass-along groups and Medicaid programs.

d. The SA level of care the person was in when they lost their SA will determine the maintenance amount for Medicaid pass-along (SA Basic or SCU).

EXAMPLE: (DAC Pass-along) Beneficiary is an adult, living alone at home who receives RSDI benefits on the record of their deceased father based on the beneficiary’s disability, which began before they were age 22.

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This beneficiary currently has no assets. The amount of their RSDI benefit is $1,200. They also receive a private pension of $500 per month and received SSI until the beneficiary’s father died in 1995. Their SSI then stopped because of receipt of RSDI benefits.

$1,200 (beneficiary’s RSDI) + $500 (private pension) $1700 (total gross income) -$1200 (disregard total RSDI) $500 - $20 (disregard) $480 (countable income is under the current SSI limit)

SDX in OVS shows status as “D.” The beneficiary is eligible for CN MAD under the DAC Pass-along

F. Recertifications At subsequent recertifications, determine if the individual still qualifies as Pass-along. Evaluate the income of the beneficiary. If the individual would be ineligible for SSI or SA under current income standards even after deducting the entire current RSDI benefit, the individual is no longer eligible as DAC Pass-along. Evaluate under other Pass-along groups and all Medicaid programs.

IV. EARLY WIDOW(ER)’S PASS-ALONG (INCLUDING SOME SURVIVING, DIVORCED SPOUSES) NOT RECEIVING MEDICARE

A. Eligibility Requirements 1. Lost SSI or SA benefits due to receipt of RSDI benefits;

2. Not yet eligible for Medicare Part A;

3. At least age 50, but not yet attained age 65; and

4. Would currently be eligible for SSI or SA benefits if they were not receiving RSDI benefits.

5. If Pass-along eligibility is based on prior receipt of SA (not SSI), the individual must currently reside in an adult care home.

B. Identify Individuals Potentially Eligible as Early Widow(er)’s Pass-along (Not Receiving Medicare) Applicants/beneficiaries need not claim Pass-along status. Many individuals may not be able to remember when or if they received SSI or SA. Fully investigate Pass-along eligibility in every case where the individual is otherwise over income for CN MAD because of income from Social Security.

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1. Use the following resources to identify individuals who lost SSI or SA eligibility:

a. SDX - The Medicaid Eligibility Code field indicates the eligibility status of “W” for a widow(er).

b. Refer to NC FAST Help job aid, Requesting and Viewing Online Data (OVS) to request SDX information in NC FAST.

c. SDX will not show SSI terminations that occurred prior to 01-01-95. If an SSI termination may have occurred prior to that date, contact SSA. d. SSI Termination/Alert Report and Ex-parte Review for SSI Termination Tasks are available in NC FAST.

(1) It is the responsibility of the county to monitor terminations of SSI benefits and evaluate individuals for all Medicaid programs.

(2) Refer to MA-1000, SSI Medicaid-Automated Process

(3) Refer to NC FAST Help Job Aid, SDX Overview, Tasks, and Work Queues.

e. Verify status by the case record or through the local SSA.

f. Individuals in adult care homes who may have been terminated from Special Assistance.

C. Verify Early Widow(er)’s Pass-along Eligibility Factors. 1. The current amount of the a/b’s RSDI benefit.

2. The a/b’s current ineligibility for Medicare Part A.

D. Early Widow(er)’s Pass-along Eligible If the Individual is determined Early Widow(er)’s Pass-along Eligible, Disregard All the RSDI Income.

E. Determine Countable Income Compare other countable earned and unearned income to the current SSI or SA Income Limit. (Use the 1/3 reduced income limit if appropriate. Refer to MA-2261 1/3 Reduction)

1. If the countable income does not exceed the current SSI or SA income limit, determine eligibility excluding RSDI benefits. This person is eligible under Early Widow(er)’s Pass-along.

2. If the countable income is above the current SSI or SA income limit, the individual is not entitled to Pass-along.

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a. DO NOT disregard the RSDI income. This person is ineligible under Early Widow(er)’s Pass-along.

b. If ineligible, count the current RSDI income and document in NC FAST.

c. Evaluate under other Pass-along groups and all Medicaid programs.

d. The SA level of care the person was in when they lost their SA will determine the maintenance amount for Medicaid pass-along (SA Basic or SCU). EXAMPLE: (Early Widow(er)’s Pass-along) The applicant is 58 years old, lives at home alone and has assets worth less than $2,000.

The applicant receives countable RSDI widow’s benefits of $1280 ($1300 minus $20 disregard) a month in 2024, which is over the Categorically Needy income limit for Medicaid. They also received SSI disability benefits beginning in 2019 until their spouse died in 2022, and the applicant became eligible for widow’s benefits. The individual doesn’t receive Medicare.

Disregarding the applicant’s entire Social Security payment would make them eligible for SSI under current rules.

$1280 (widow(er)’s benefit) -$1280 (disregard total Widow’s benefit) 0

-$20 (disregard) 0 (countable income is under the current SSI limit)

The applicant is eligible for CN MAD under the Widow(er)’s Pass-along.

F. Recertifications At subsequent recertifications, determine if the individual still qualifies as Pass-along. Evaluate the income of the beneficiary. If the individual would be ineligible for SSI or SA after disregarding the RSDI income, the individual is no longer eligible as Early Widow(er)’s Pass-along. Evaluate under other Pass-along groups and all Medicaid programs.

V. DISABLED WIDOW(ER)’S PASS-ALONG (INCLUDING SOME UNMARRIED, DIVORCED SPOUSES) WHO LOST SSI IN 1984 A. Eligibility Requirements 1. Be disabled (or were determined disabled by SSA until age 65).

2. Have received SSI or SA benefits in December 1983 but lost eligibility in January 1984 due to a statutory elimination of an additional benefit reduction factor for

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widow(er)s before age 60 who were entitled to widow(er)s benefits based on disability since January 1984. 3. Would currently be eligible for SSI or SA except for the receipt of RSDI benefits.

4. If Pass-along eligibility is based on former receipt of SA, the individual must currently reside in an adult care home.

B. Identify Individuals Who Lost SSI Eligibility. Applicant/beneficiaries need not claim Pass-along status. Many individuals may not be able to remember when or if they received SSI or SA.

Fully investigate Pass-along eligibility in every case where the individual is otherwise over income for CN MAD because of income from Social Security.

Use the following resources to identify individuals who lost SSI or SA eligibility:

1. The RSDI Claim number suffix will be “D” or “W” if the a/b receives as a disabled widow(er)/surviving divorced spouse.

2. SDX - The Medicaid Eligibility Code field indicates the eligibility status of “W” for a widow(er).

3. SSI Termination/Alert Report is available in NC FAST.

a. It is the responsibility of the county to monitor terminations of SSI benefits and evaluate individuals for all Medicaid programs.

b. Refer to MA-1000, SSI Medicaid-Automated Process

c. Refer to NC FAST Help Job Aid, SDX Overview, Tasks, and Work Queues. 4. For individuals receiving as a Disabled Widow(er) prior to January 1, 1995, verify status by the case record or through SSA.

C. Verify Disabled Widow(er)’s Eligibility Factors. 1. The date SSI benefits were terminated.

2. The current amount of the a/b’s RSDI Disabled Widow benefit.

D. Disabled Widow(er)’s Eligibility If the Individual is determined Disabled Widow(er)’s Pass-along Eligible, Disregard All the RSDI Income.

E. Determine Countable Income

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Compare other countable earned and unearned income to the current SSI or SA income limit. (Use the 1/3 reduced income limit if appropriate.)

1. If the countable income does not exceed the current SSI or SA income limit, determine eligibility excluding RSDI benefits. This person is eligible under Disabled Widow(er)’s Pass-along.

2. If the countable income exceeds the current SSI or SA income limit, the individual is not entitled to Disabled Widow(er)’s Pass-along. a. DO NOT disregard the RSDI income. This person is ineligible under Disabled Widow(er)’s Pass-along.

b. If ineligible, count the current RSDI income and document in NC FAST.

c. Evaluate under other Pass-along groups and all Medicaid programs.

d. The SA level of care the person was in when they lost their SA will determine the maintenance amount for Medicaid pass-along (SA Basic or SCU).

EXAMPLE: (Disabled Widow(er)’s Pass-along) The applicant is a 60-year-old disabled widow who lives at home and has assets worth less than $2,000.

In November 1983, the applicant began receiving SSI benefits. However, in January 1984 they lost those benefits due to a statutory elimination of an additional benefit reduction factor for widow(er)s before age 60 who were entitled to widow(er)s benefits based on disability.

They currently receive countable RSDI widow’s benefits of $1260 ($1280 minus $20 disregard) a month which is over the Categorically Needy income limit for Medicaid. The individual doesn’t receive Medicare. Disregarding the applicant’s entire Social Security payment would make them eligible for SSI under current rules.

$1.280 (widow(er)’s benefit) -$1,280 (disregard total Widow’s benefit)

-$20 (disregard) 0 (countable income is under the current SSI limit)

The applicant is eligible for CN MAD under the Widow(er)’s Pass-along.

F. RECERTIFICATIONS At subsequent recertifications, determine if the individual still qualifies as Pass-along. Evaluate the income of the beneficiary. If the caseworker determines that the a/b is ineligible after evaluating other income, along with any Pass-along, the individual is no longer eligible as Pass-along. If ineligible, count the RSDI income. Evaluate the a/b for all other MAGI and NON-MAGI Medicaid programs.

North Carolina Department of Health and Human Services Division of Medical Assistance Medicaid Eligibility Unit AGED, BLIND, AND DISABLED MEDICAID MANUAL Transmitted by Change No. 15-03

MA-2120

MEDICALLY NEEDY REGULATIONS 12/01/02 MA-2120: MEDICALLY NEEDY REGULATIONS{ XE "MEDICALLY NEEDY REGULATIONS" } 12/01/02

I. INTRODUCTION TO MEDICALLY NEEDY (M)

Medically Needy is a Medicaid classification for aged, blind, or disabled individuals whose countable income and/or resources exceed the categorically needy limits. Medically Needy coverage extends Medicaid to needy aged, blind, and disabled individuals who have too much income/resources to receive SSI, but not enough to pay for medical care. This section defines the requirements to determine eligibility as Medically Needy. Always evaluate aged, blind or disabled individuals who are financially ineligible as Categorically Needy under Medically Needy regulations.

II. POLICY RULES FOR MEDICALLY NEEDY{ XE "MEDICALLY NEEDY POLICY RULES" }

A. Meet the Eligibility Requirements in MA-2000, Non-SSI Eligibility Regulations

B. Medically Needy Income Limits{ XE "Medically Needy Income Limits" }

When an individual/couple’s countable income exceeds the categorically needy income limit, compare his income to the MN income limits. Refer to MA-2260, Financial Eligibility Regulations

C. Resource Limit{ XE "Medically Needy Resource Limit" }

The resource limit for individuals/couples under MN is the same as the Categorically Needy resource limits. Refer to MA-2260, Financial Eligibility Regulations.

D. Reduction of Resources{ XE "Medically Needy, Reduction of Resources" }

The resource limit and countable resources are the same as Categorically Needy. However, for Medically Needy eligibility an individual whose countable resources exceed the resource limit as of the “first moment of the month” can establish eligibility on the day of the month that the value of countable resources is reduced within the allowable limits. Refer to MA-2230, Financial Resources.

E. Deductible{ XE "Deductible" }

Only individuals evaluated as Medically Needy can have a deductible.

1. When the net countable income for an individual/couple exceeds the medically needy income limit, the individual/couple has a deductible.

2. The deductible is met by incurring medical expenses equal to the amount of the excess income. 1

AGED, BLIND, AND DISABLED MEDICAID MANUAL Transmitted by Change No. 15-03

MA-2120

MEDICALLY NEEDY REGULATIONS 12/01/02 (II.E.) 3. The deductible is based on income in a 6 month certification period. An exception is when an individual applies for Medicaid as MN before his SSI Medicaid terminates. In this situation, the deductible is based on income beginning with the month after SSI Medicaid terminates through the end of the 6 month certification period. Refer to MA-1000, SSI Medicaid – Automated Process, for instructions on SSI Medicaid terminations.

See MA-2360, Medicaid Deductible, for rules and procedures to establish deductible and allowable expenses to be applied to the deductible.

F. Classification{ XE "Medically Needy Classification" }{ XE "Classification for Medically Needy" }

The classification in EIS is “M”, or “B”, if the individual is dually eligible.

Refer to the EIS Manual for special Medically Needy codes for aliens.

G. Certification/Authorization{ XE "Medically Needy, Certification/Authorization" }{ XE "Certification/Authorization, Medically Needy" }

The ongoing c.p. for cases evaluated as MN is always 6 months.

1. The 6 month c.p. begins with the month of application.

2. Authorization begins the date all eligibility criteria are met. In cases of excess resources and/or deductible that is the date countable resources are reduced to the resource limit or the date the deductible is met, whichever is later.

Refer to MA-2350, Certification/Authorization, for further instructions.

H. Buy-In{ XE "Medically Needy, Buy-In" }{ XE "Buy-In, Medically Needy" }

For MN cases, the buy-in effective date is the first day of the second month following authorization for Medicaid.

Refer to MA-2410, Buy-In, for procedures. 2

North Carolina Department of Health and Human Services North Carolina Medicaid Division of Health Benefits AGED, BLIND AND DISABLED MEDICAID MANUAL MA-2130

QUALIFIED MEDICARE BENEFICIARIES - Q

1

REVISED 12/03/2018 – CHANGE NO. 06-18

Current Change Notice: 06-18 • The Qualified Medicare Beneficiaries policies have been revised in the online Adult Medicaid Manual in the following sections: MA-2130, Qualified Medicare Beneficiaries – Q

I. QUALIFIED MEDICARE BENEFICIARIES - Q

An applicant/beneficiary (a/b) who is enrolled in Medicare Part A and B, and has income at or less than 100% of poverty is eligible for the state to buy-in payment of the Medicare premiums, deductibles and coinsurance. Buy-in is effective the first day of the month after the month of disposition with “Q” Medicaid classification. No additional benefits are provided under this program. Medicaid card will be issued to beneficiaries authorized for MQB-Q. The beneficiary may meet the eligibility requirements for both MAABD and MQB-Q.

II. MQB-Q ELIGIBLITY REQUIREMENTS

A. Meet all Financial/Non-financial eligibility requirements.

B. Be Enrolled in Medicare Part A and B.

1. Refer to MA-2410, Medicare Enrollment and Buy-In, for an explanation of Medicare enrollment procedures.

2. MQB-Q beneficiary who is already enrolled in Medicare Part B will need to apply for Medicare Part A.

3. Verify Medicare coverage by seeing one of the following:

a. OVS

b. The Medicare card

c. BENDEX (Part B is SMI entitlement and Part A is HIB entitlement)

d. EOB - Explanation of Benefits

e. Note: Inmates of public institutions are not eligible for Medicare.

C. Income

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1. Countable income cannot exceed 100% of the current Federal Poverty Level (FPL). This level is adjusted in April of each year.

2. Refer to MA-2260 Financial Eligibility Requirements-PLA, for current income levels.

D. Resources

Refer to MA-2260 Financial Eligibility Requirements-PLA, for countable resource limits.

III. MQB-Q SPECIAL PROGRAM REQUIREMENTS

A. Limited Coverage 1. Under the MQB-Q program Medicaid pays Medicare Part A and B premiums, deductibles, and coinsurance for charges covered by Medicare. MQB-Q does not pay toward any services which are not covered by Medicare, such as eyeglasses, and dental care.

2. MQB beneficiaries do not qualify for Non-Emergency Medical Transportation.

3. Medicare participating physicians and suppliers are required to file all Medicare claims and to accept Medicare assignment if the Medicare beneficiary is MQB eligible for dates of service.

4. MQB-Q beneficiaries receive a Medicaid card.

B. Dual Eligibility 1. The beneficiary (or couple) may meet the eligibility requirements for both MAABD and MQB-Q. This is known as dual eligibility.

2. The beneficiary must be evaluated for all Medicaid programs.

C. Application Processing Requirement 1. The application processing standard is 45 days.

2. If the applicant is not enrolled in Medicare Part A and B with SSA by the application processing standard or denied entitlement to Medicare, evaluate for all other Medicaid programs.

D. Classification The classification is “Q”, even if dually eligible.

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E. Certification Period 1. The certification period always begins with the month of application.

2. The certification period is 12 months. F. MQB-Q Authorization 1. Always begins the first day of the month after the month of disposition. The date of disposition is the date the DMA-5002/5002s is sent.

2. For recertification, authorization begins the first month of the new certification period if all eligibility criteria are met.

G. Retroactive Coverage 1. The applicant/beneficiary (a/b) can never receive MQB-Q coverage retroactively since benefits can begin no earlier than the month after disposition.

2. If the a/b has a retroactive need for the months prior to the MQB-Q certification period, evaluate for coverage for the retroactive months in another aid program/category.

3. Dual eligibility for MAABD and MQB-Q can never apply to retroactive months.

H. Cost of Living Allowance (COLA) 1. Exclude the monthly amount of the RSDI COLA from countable income in determining eligibility for January, February, and March of each year. Use the prior December amount to determine eligibility for January through March. Effective April 1 begin counting the increased monthly RSDI benefit that was effective in January.

2. When the COLA increase is greater than the Federal Poverty Level, some Medicaid beneficiaries may lose eligibility or move to deductible status. In this situation, the most recent COLA must be disregarded in determining continued eligibility. If the beneficiary remains eligible when the SSA COLA is disregarded, the disregard continues until the beneficiary loses Medicaid eligibility or becomes eligible without the disregard.

I. Recertification 1. Apply the ex-parte process prior to the end of the certification period.

2. Verify the following eligibility factors at every recertification:

a. Medicare Entitlement

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b. Living Arrangement

c. Reserve

d. Income

North Carolina Department of Health and Human Services North Carolina Medicaid Division of Health Benefits AGED, BLIND AND DISABLED MEDICAID MANUAL MA-2140

QUALIFIED MEDICARE BENEFICIARIES - B

1

REVISED 12/03/2018 – CHANGE NO. 06-18

Current Change Notice: 06-18 • The Qualified Medicare Beneficiaries policies have been revised in the online Adult Medicaid Manual in the following section: MA-2140, Qualified Medicare Beneficiaries - B

I. QUALIFIED MEDICARE BENEFICIARIES - B

An applicant who is enrolled in Medicare Part A, and has income greater than100% and equal to or less than 120% of poverty is eligible for the state to buy-in payment of the Medicare Part B premium. Buy-in is effective the month of authorization with “B” Medicaid classification. No additional benefits are provided under this program. No Medicaid card will be issued to beneficiaries authorized for MQB-B. The beneficiary may meet the eligibility requirements for both MAABD and MQB-B.

II. MQB-B ELIGIBILITY REQUIREMENTS

A. Meet all Financial/Non-financial eligibility requirements.

B. Medicare

Enrolled in Medicare Part A and has an RSDI claim number or Railroad Retirement number. Verify Medicare coverage by checking one of the following:

1. OVS

2. For Railroad Retirement benefit verification, contact the Railroad Retirement Board at 1-800-808-0772, or online at https://www.rrb.gov and select “Benefit Online Services.”

3. The Medicare Card

4. Bendex (Part B is SMI entitlement and Part A is HIB entitlement)

5. Medicare EOB (Explanation of Benefits)

6. Inmates of public institutions are not eligible for Medicare.

C. Ineligible for MQB-Q

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Meets all MQB-Q financial eligibility criteria, except that; income exceeds 100% federal poverty limit (FPL).

D. Income

1. Must have countable monthly income greater than 100% and not to exceed 120% of the federal poverty limit.

2. Refer to MA-2260, Financial Eligibility Requirements-PLA, for current MQB-B income levels.

3. Refer to MA-2260.V, MQB Family Size Budgeting, if the income exceeds 120% of the federal poverty limit.

E. Resources

Refer to MA-2260, Financial Eligibility Requirements-PLA, for current resource levels.

III MQB-B SPECIAL PROGRAM REQUIREMENTS

A. Limited Coverage

1. MQB-B pays only the Medicare Part B premium.

2. MQB-B beneficiaries do not receive a Medicaid card.

3. MQB-B beneficiaries do not qualify for Non-Emergency Medical Transportation.

B. Dual Eligibility

1. A beneficiary may be dually eligible for MAABD and MQB-B. 2. A beneficiary must be evaluated for all other Medicaid programs for which they may be qualify. C. Processing Requirements

1. The application processing time standard is 45 days.

2. If the applicant will not be enrolled and covered by Medicare Part A and Part B by the application processing standard, deny the MQB-B application according to procedures in MA-2300, Application.

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a. An applicant who is eligible for premium-free Part A, but does not enroll during his enrollment period, can enroll only during the months of January through March of each year.

b. Medicare Part A coverage is effective July 1st of the enrollment year.

2. If the applicant will be covered by Medicare Part A and Part B prior to the processing deadline, the case may be authorized effective with the month of Part A coverage.

D. Disposition

If the applicant is eligible, approve MQB-B. Use the DMA-5002 or the DMA-5002S, to notify the applicant/beneficiary (a/b).

E. Classification

The classification is “B”, even if dually eligible. F. Certification Period

1. The certification period begins with the month of application.

2. The certification period is 12 months.

G. Authorization

Authorize effective the month of application if all eligibility criteria are met.

For recertification, authorization begins the first month of the new certification period if all eligibility criteria are met.

H. Retroactive Period

Unlike MQB-Q coverage, coverage for Medicare Part B only (MQB-B) can be authorized retroactively for three months prior to the month of application. Always provide retroactive MQB-B coverage if the applicant meets eligibility criteria and is not already covered under MAABD.

Medical need is not an issue for MQB-B retroactive coverage. It is a requirement for MAABD.

I. Cost of Living Allowance (COLA)

1. Exclude the monthly amount of the RSDI COLA from countable income in determining eligibility for January, February, and March of each year. Use the prior December amount to determine eligibility for January through

4

March. Effective April 1st begin counting the increased RSDI benefit that was effective in January.

2. When the COLA increase is greater than the Federal Poverty Level, some Medicaid beneficiaries may lose eligibility or move to deductible status. In this situation, the most recent COLA must be disregarded in determining continued eligibility. If the individual remains eligible when the SSA COLA is disregarded, the disregard continues until the beneficiary loses Medicaid eligibility or becomes eligible without the disregard.

J. Recertification

1. Apply the ex-parte process prior to the end of the certification period.

2. Verify the following eligibility factors at every recertification:

a. Medicare entitlement a. Living Arrangement b. Reserve c. Income

North Carolina Department of Health and Human Services Division of Medical Assistance Medicaid Eligibility Unit AGED, BLIND, AND DISABLED MEDICAID MANUAL Transmitted by Change No. 12-05

MA-2150

AGED, BLIND AND DISABLED- MEDICAID WORKING DISABLED 02/01/05

MA-2150: MEDICAID-WORKING DISABLED 02/01/05

I INTRODUCTION TO M-WD

An eligible Qualified Disabled Working Individual (M-WD, Working Disabled) is eligible for Medicaid payment of Medicare Part A premiums after automatic entitlement to free Part A ends. This is the only Medicaid benefit to which he is entitled.

UNLESS OTHERWISE NOTED BELOW, THE SAME REQUIREMENTS AND PROCEDURES APPLY TO M-WD AND MQB-Q.

II. MWD ELIGIBILITY REQUIREMENTS

To be eligible to receive this coverage, an individual must:

A. Be under age 65.

B. Have countable monthly income under 200% of the Federal Poverty Level (FPL).

Refer to MA-2260, Financial Eligibility Requirements/PLA, for current income levels.

C. Continue to have the disabling physical or mental impairment that he had when he was determined disabled or blind by the Social Security Administration (SSA).

D. Have lost entitlement to premium free Medicare Part A solely due to earnings in excess of the Substantial Gainful Activity threshold as determined by SSA.

NOTE: This is a standard set by SSA. SSA will make this determination.

E. Not be otherwise entitled to premium free Medicare Part A.

F. Furnish his Medicare claim number.

G. Not be otherwise eligible for Medicaid.

III. M-WD SPECIAL REQUIREMENTS

A. Limited Coverage

M-WD covers the Medicare A premium (hospital insurance) only. If the individual wants Part B (medical insurance), he must pay for it.

B. Application Processing Requirements

1. Obtain applicant’s signature on the DSS-8124 or the DMA-5008. Complete the DMA-5008. Do not enter a DSS-8124 into EIS.

2. The time standard for M-WD application is 45 days. Manually track and follow processing requirements in MA-2300 through MA-2304.

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AGED, BLIND, AND DISABLED MEDICAID MANUAL Transmitted by Change No. 12-05

MA-2150

AGED, BLIND AND DISABLED-MEDICAID WORKING DISABLED 02/01/05 (III.) C. Disabled Working Status

SSA must verify Disabled Working status.

D. Disposition

NOTE: M-WD cases will not be entered into EIS. Once the county dss determines eligibility each case will be manually processed at DMA.

1. If the a/r is eligible, approve M-WD and send a DSS-8108. On the DSS-8108 write “You meet the N.C. eligibility requirements for M-WD and are eligible to have the State pay your Medicare Part A premiums.”

2. Once eligibility has been established, send a cover letter within 5 work days to DMA providing the following information on the individual:

a. Full name

b. Medicare number

c. Date of birth

d. Sex

e. Medicare Part A Premium enrollment date

f. SSA Disabled Working status notification letter

3. Send to:

Attn: Supervisor Claims Analysis Unit Division of Medical Assistance 2501 Mail Service Center #19 Raleigh, N.C. 27699-2501

E. Retroactive Coverage

If the individual meets the eligibility criteria prior to the month of application, he may be eligible for retroactive coverage for up to 3 prior months provided he has enrolled timely at SSA.

F. Reviews

1. Since this program is not in EIS, the county dss must initiate a review notice and send the appointment letter prior to expiration of the certification period.

2. Send DMA a copy of the notice if ongoing eligibility continues.

G. Termination

If the recipient becomes ineligible, terminate the case and notify DMA.

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North Carolina Department of Health and Human Services North Carolina Medicaid Division of Health Benefits AGED, BLIND AND DISABLED MEDICAID MANUAL MA-2160

QUALIFIED INDIVIDUAL 1 (MQB-E)

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REVISED 12/03/2018 – CHANGE NO. 06-18

Current Change Notice: 06-18 • The Qualified Medicare Beneficiaries policies have been revised in the online Adult Medicaid Manual in the following sections: MA-2160, Qualified Individual 1 (MQB-E)

I. INTRODUCTION TO QUALIFYING INDIVIDUALS

Qualifying Individuals (QI1s/MQB-E) are beneficiaries who would be eligible for MQB- B except that their income is between 120 - 135% of the federal poverty limit. QI1s are also referred to as MQB-E.

Although eligibility regulations and benefits for QI1/MQB-E are the same as for MQB-B, the law mandates differences from the current MQB-B:

A. It is a capped entitlement. Funding is based on a fixed allocation at 100% Federal Financial Participation (FFP) through December of the current calendar year.

B. Approval is based on a first-come, first-served basis. When the number of QI1/MQB-E cases reach the capped allotment, Division of Health Benefits (DHB) will provide state wide notice to no longer approve applications for QI1/MQB-E.

C. There is no six month or 12 month certification period. Depending on the date the QI1/MQB-E application is taken, the certification period ends on December 31 of the current calendar year or December 31 of the next calendar year.

D. QI1/MQB-Es cannot be otherwise eligible or dually eligible for other Medicaid program.

II. QUALIFYING INDIVIDUALS POLICY FUNDAMENTALS

A. Eligibility

Except as noted below, the eligibility requirements and methodology for QI1/MQB- Es are the same as for MQB-B.

Inmates of public institutions are not eligible for Medicare

B. Income

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Must have countable monthly income between 120% and 135% of the federal poverty limit.

Refer to MA-2260, Financial Eligibility Requirements/PLA, for current QI1/MQB-E income levels.

C. Medicaid Program Classification

The Medicaid program classification code is MQB-E. D. Coverage Coverage for QI1/MQB-E is the same as for MQB-B. The only benefit is payment of the Part B Medicare premium. No Medicaid card is issued.

E. Retroactive Coverage

Like MQB-B, QI1/MQB-Es can be authorized for retroactive coverage for up to 3 months prior to the month of application. However, coverage can never be authorized for a period prior to January of the current year.

F. No Dual Eligibility

Unlike MQB-Q and MQB-B, a QI1/MQB-E cannot be dually or otherwise eligible for Medicaid. This means an:

1. Applicant/beneficiary (a/b) authorized for Medicaid in any other program (MAABD, SAAD, MAF, etc.) is not eligible for QI1/MQB-E, and

2. A/b whose application is pending to meet a deductible is not eligible for QI1/MQB-E, and

3. Ongoing beneficiary placed in deductible status is not eligible for QI1/MQB-E unless the a/b elects to change coverage solely to QI1/MQB-E.

G. Processing Requirements

1. The application processing standard is 45 days.

2. QI1/MQB-E is subject to monitoring. Refer to MA-2305, Evaluating County/DDS Performance.

H. Ongoing Certification Period

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1. QI1/MQB-Es do not have a standard six or 12 month certification period (C.P.). The ongoing C.P. begins with the month of application for QI1/MQB- E.

2. If a QI1/MQB-E a/b subsequently becomes eligible under MAABD (or other Medicaid program), the C.P. is not based on the ongoing QI1/MQB-E C.P. The C.P. begins with the month the a/b requests assistance under the new Medicaid program.

I. Recertification

Eligibility is re-evaluated for each calendar year. Refer to IV., below for recertification procedures.

III. PROCEDURES

A. Application

1. Refer to MA-2300, Application. If an a/b/couple’s income is in the QI1/MQB-E range, compute the estimated deductible for the ongoing and retro period.

2. Evaluate whether the applicant is likely to meet their deductible based on unpaid old bills, ongoing monthly expenses, and anticipated new medical expenses. Do a separate evaluation for the ongoing and retro period and document this evaluation.

3. Explain to the applicant that they must choose between applying for QI1/MQB-E and only receiving payment of their Part B premium or applying for MAABD and pending to meet a deductible for either the retro and ongoing period. Be sure the applicant understands the benefits and effective dates for both programs.

4. Document in the case the explanation and choice of program. If the applicant applies for QI1/MQB-E, a DMA-5095, Medicaid/WF Notice of Inquiry, is not required.

B. Application Disposition

1. Refer to MA-2300, Application to disposition the QI1/MQB-E case.

2. QI1/MQB-E applications dated before November of each year and not approved until on or after November, the C.P. end on 12/31 of the current year.

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3. QI1/MQB-E applications dated after November 1st or later, the C.P. end on 12/31 of the next year.

3. DHB monitors the number of approvals and will notify counties when the federal funds for QI1/MQB-E will be exhausted for the current year. At that time DHB will issue instructions to dispose any pending QI1/MQB-E applications.

C. Change in Situation/Program Transfers

1. Pending QI1/MQB-E Application

If you learn a QI1/MQB-E applicant has a change in situation and is eligible for MAABD (or under another Medicaid program):

a. Disposition the QI1/MQB-E application:

(1) Approve the case if the a/b was eligible for QI1/MQB-E during any of the retro or ongoing period not covered by full Medicaid, or (2) Process an administrative application if the a/b is eligible for full Medicaid for the entire period covered by the QI1/MQB-E application.

b. If the a/b is not in the agency, the application may be unsigned. However, the new application is subject to all application processing requirements.

c. The date of application is the date the application is signed or the date the applicant (representative, nursing facility, hospital, etc.) requested assistance.

d. If otherwise eligible, the MAABD 6 month ongoing C.P. or 3 month retro C.P. is based on the MAABD date of application, not the QI1/MQB-E date of application. e. If you learn a pending QI1/MQB-E application should be a MQB-Q or

MQB-B application due to the income or a pending MQB-Q or MQB-B

should be a QI1/MQB-E application, process an administrative denial

application. Evaluate for all other Medicaid programs. Do not change the

date of application.

2. Pending MAABD application

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When an a/b with income in the QI1/MQB-E range who chose to pend to meet a deductible changes their mind and requests QI1/MQB-E:

a. Process an administrative application, to deny the MAABD application.

b. Evaluate for all other Medicaid programs. This is a QI1/MQB-E application. This application may be unsigned if the a/b is not in the agency.

c. The date of application is the date the application is signed or the date the a/b requests assistance.

d. If otherwise eligible, the QI1/MQB-E certification period is based on the QI1/MQB-E month of application. However, regardless of the QI1/MQB- E date of application, QI1/MQB-E authorization can never begin earlier than the calendar month the MAABD application is denied.

3. Denied MAABD application

When an application is denied for failure to meet the deductible and the individual has income in the QI1/MQB-E range, take the following actions:

a. Evaluate the a/b is still eligible for QI1/MQB-E.

b. If so, follow instructions in 1., above.

c. If the a/b is otherwise eligible and the federal funds have not been exhausted, begin QI1/MQB-E coverage the calendar month the MAABD application is denied.

4. Ongoing QI1/MQB-E beneficiary becomes eligible for full Medicaid

When a QI1/MQB-E beneficiary has a change, which makes them eligible for full Medicaid take the following actions:

a. Evaluate for other Medicaid programs.

b. Review the case to see what the beneficiaries reserve was when it was approved for QI1/MQB-E. If it was below $2,000/3,000 and there is no change in situation affecting reserve, no further verification is required until the next review. If the reserve was greater than $2,000/3,000, verify reserve in the same manner that is done at recertification.

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c. If the beneficiary requests retro Medicaid only, process the application. This is an administrative application. The date of application is the date the application is signed or the date the a/b requests assistance. If otherwise eligible, approve case. This will allow the QI1/MQB-E to continue for the remainder of the QI1/MQB-E certification period.

d. If the beneficiary requests retro and ongoing full Medicaid or ongoing Medicaid only, an application is not necessary. This is an administrative application.

e. The MAABD retro C.P. is the 3 calendar months prior to the month the a/b requests assistance. The 6-month or 12-month ongoing certification period begins the month the A/B requests assistance. The MAABD C.P. is not tied to the original QI1/MQB-E date of application.

f. If the QI1/MQB-E beneficiary is ineligible for full Medicaid, document the request and the reason the Medicaid program was not changed.

5. MAABD, MQB-Q, MQB-B, SAAD beneficiary loses eligibility.

When a beneficiary is terminated from a Medicaid program and their income is in the QI1/MQB-E range, take the following action: a. Review the case. b. If the a/b is otherwise eligible and the federal funds have not been exhausted, the beneficiary is not required to make an application. Process an administrative application.

c. QI1/MQB-E coverage cannot begin until the month following the month full Medicaid terminates.

d. The end date depends on the QI1/MQB-E date of application. If the QI1/MQB-E date of application is January 1 through October 31, the end date is 12/31 of the current calendar year. If the QI1/MQB-E date of application is 11/01 or later, the end date is 12/31 of the next calendar year.

IV. RECERTIFICATION

A. Ex-parte process 1. Complete an ex-parte and evaluate for all other Medicaid programs by the 2nd to last business day of December.

2. The caseworker is required to:

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a. Conduct all electronic matches, including OVS b. Check other available records c. Contact beneficiary only if continuing eligibility cannot be determined by available information

d. Issue a DMA-5097, Request for Information, allowing the beneficiary 12 calendar days to return the information.

B. Cost of living Allowance (COLA) 1. Always use the December Social Security benefit to determine eligibility under MQB-E. The RSDI COLA is excluded from countable income for January, February, and March of each year.

2. When the COLA increase is greater than the Federal Poverty Level, some Medicaid beneficiaries may lose eligibility or move to deductible status. In this situation, the most recent COLA must be disregarded in determining continued eligibility. If the beneficiary remains eligible when the SSA COLA is disregarded, the disregard continues until the beneficiary loses Medicaid eligibility or becomes eligible without the disregard.

C. MQB-E certification period is January through December of the next calendar year.

D. Information Not Received If the information needed is not retuned, send a timely notice to terminate the case. E. If the information necessary to determine eligibility is received after the case has been terminated, process an application.

1. Do not require the beneficiary to complete and sign a new application. 2. Enter a reapplication in NC FAST. Application processing standards apply. 3. The date of application is the date the necessary information was received.

North Carolina Department of Health and Human Services North Carolina Medicaid Division of Health Benefits AGED, BLIND AND DISBALED MEDICAID MANUAL MA-2170 FAMILY PLANNING PROGRAM 1 REVISED 11/3/2021 – CHANGE NO. 10-21 I. Introduction The Medicaid Family Planning Program (FPP) establishes a system by which individuals, regardless of age, gender, or disability status, more easily access family planning and family planning related services to prevent/reduce unplanned pregnancies. FPP also includes Non-Emergency Medical Transportation (NEMT) for FPP services only.

A. Eligibility Requirements

1. No age restrictions

2. Not Pregnant

3. Have income at or below 195% of the FPL 4. Meet all financial and non-financial eligibility requirements

B. Determine Eligibility

Determine Family Planning Program (FPP) eligibility when all verifications necessary to determine FPP have been received and authorize if otherwise eligible the first day of the application month.

Do NOT delay processing the FPP application while pending verifications for other Non-MAGI applications. This includes but is not limited to:

1. Pending disability determination, 2. Pending medical bills to meet a deductible or 3. Reserve reduction/verification for applicable programs.

Apply MAGI budgeting methodologies to individuals in the Family Planning Program.

C. Certification Period

The certification period is 12 months for an ongoing case. The certification period can be adjusted to match the family’s other Medicaid cases.

D. Retroactive Eligibility

2 Retroactive eligibility can be determined for 1, 2 or 3 months prior to the application. If the individual applies for retro coverage and they are determined to be categorically eligible for any program including FPP, authorize the case. The worker is not required to verify need unless the individual would have to meet a deductible in the retro period.

E. Redetermination

Using the ex parte process, evaluate for all other Medicaid programs prior to authorizing continued Family Planning Program.

F. Change in Circumstance

Changes include, but are not limited to, changes in:

1. income,

2. household,

3. disability status or

4. ability to meet a deductible.

When a change in circumstance is reported, evaluate for all Medicaid programs. Determine eligibility within 30 days. Refer to MA-3306 MAGI Income, MA-2250 Income, MA-2525 Disability, to determine appropriate action.

North Carolina Department of Health and Human Services North Carolina Medicaid Division of Health Benefits AGED, BLIND AND DISABLED MEDICAID MANUAL MA-2180

HEALTH COVERAGE FOR WORKERS WITH DISABILITIES

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REVISED 4/30/26 – CHANGE NOTICE 05-26 I. Introduction to Health Coverage for Workers with Disabilities

The federal Ticket to Work and Work Incentives Improvement Act (TWWIIA) of 1999 offers states the option to protect Medicaid coverage for workers with disabilities. People with disabilities are often discouraged from working for fear that their earnings would make them ineligible for Medicaid. TWWIIA offers state Medicaid programs options to expand Medicaid eligibility criteria for workers with disabilities.

II. Background

North Carolina is authorized to provide Medicaid for disabled/blind workers under the Health Coverage for Workers with Disabilities Act (G.S. 108A-54.1). Health Coverage for Workers with Disabilities (HCWD) provides an incentive for people with disabilities to go to work or to increase their hours of work while protecting their Medicaid eligibility.

HCWD covers blind or disabled workers age 16 through 64 regardless of total countable income or CAP status. However, there is a limit on unearned income of 150% of the federal poverty level. The resource limit is the minimum community spouse resource allowance. Refer to MA-2231, Community Spouse Resource Protection policy. HCWD beneficiaries are entitled to full Medicaid coverage under Medicaid for the Blind or Visually Impaired (MAB) or Medicaid Disabled (MAD). Beneficiaries aged 16 through 20 are also entitled to additional services provided under Early and Periodic Screening, Diagnostic, and Treatment (EPSDT). Refer to MA-2905, Medicaid Covered Services policy. HCWD consists of two groups, the Basic Coverage Group and the Medically Improved Coverage Group.

III. COVERAGE GROUPS

A. Basic Coverage Group The Basic Coverage Group consists of beneficiaries aged 16 through 64 who, except for engaging in substantial gainful activity, would meet the Social Security/ Supplemental Security Income (SSI) disability criteria, or who do not engage in substantial gainful activity but are over income and/or reserve for regular MAD. Refer to MA-2525, Disability policy.

B. Medically Improved Coverage Group

1. The Medically Improved Group consists of beneficiaries aged 16 Docusign Envelope ID: B8C63DC7-7367-4210-853E-B7B004802EE4

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through 64 who previously received HCWD in the Basic Coverage Group but lost eligibility in this group because their medical conditions improved to the point where they no longer meet the Social Security/SSI definition of disability.

2. Although no longer considered disabled by Social Security due to medical improvement, the individual must continue to have a severe medically determinable impairment.

3. Eligibility in the Basic Group for any period of time qualifies an individual for eligibility in the Medically Improved Group if they meet all other eligibility requirements.

4. Eligibility in the Medically Improved Group can begin no earlier than the month after coverage ends in the Basic Group.

IV. ELIGIBILITY REQUIREMENTS

A. Generally

To be eligible to receive HCWD, a beneficiary must:

1. Be at least 16 years of age, but less than 65 years of age.

2. Meet the Social Security Administration (SSA) definition of disability except for earnings or being eligible under the Medically Improved Group.

3. Be employed. 4. Have countable resources equal to or less the minimum community spouse resource allowance. Refer to MA-2231, Community Spouse Resource Protection policy, whether budgeted as an HCWD individual or HCWD couple. 5. Meet the income requirements for their coverage group.

B. Meet all the other eligibility requirements applicable to Adult Medicaid coverage groups. Refer to MA-2000, Non-SSI Eligibility Regulations policy.

C. Disability To be eligible in the Basic Coverage Group, the applicant/beneficiary (a/b) must meet the Social Security/SSI definition of disability other than the requirement that the a/b not be engaged in a substantial gainful activity. Disability can be proven by 1, 2 or 3 below.

Docusign Envelope ID: B8C63DC7-7367-4210-853E-B7B004802EE4

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1. Receipt of Social Security Disability or SSI.

2. A determination by Disability Determination Services (DDS).

a. If an HCWD applicant is not receiving Retirement, Survivors, and Disability Insurance (RSDI)/SSI and has not been determined disabled by DDS or a Hearing Officer, he must be referred to DDS for a determination to ensure that he meets the definition of disability. Use the DDS referral form, DHB-4037, Disability Determination Transmittal. Refer to MA-2525, Disability policy, for instructions.

(1) Refer the applicant to the local SSA office to apply for RSDI and suggest that the applicant also apply for SSI. (2) If the applicant is found to be disabled by DDS but is later denied SSI/RSDI, the DDS disability approval remains valid for HCWD eligibility purposes. Do not terminate an HCWD recipient for having been denied SSI/RSDI.

(3) If prior to receiving a disability determination from DDS the local county determines that the applicant is ineligible for MAD or HCWD, immediately contact DDS and tell them of this determination and that a disability determination is no longer necessary. Denying the application which updates the DDS data screen is not sufficient. Refer to MA-2525 Disability policy for DDS contact numbers.

b. If an HCWD applicant is not receiving RSDI/SSI but was previously determined to be disabled by SSA, DDS or a Hearing Officer, they still may be considered disabled for HCWD purposes. The case manager must consider the reason for the termination as well as the length of time between termination of RSDI or SSI benefits, the DDS decision, or the Hearing Officer’s decision and application for HCWD.

(1) If the termination of RSDI or SSI benefits, or the DDS decision or the Hearing Officer’s decision occurred 12 months or less prior to the date of application and the termination was for non-medical reasons, a DDS determination of disability is not necessary.

Example: The month of application for HCWD is November 2024. SSI was terminated for non-medical reasons in November 2025. This is 12 months prior to the month of application and therefore the requirement is met (November 1, 2024 – October 31, 2025).

Docusign Envelope ID: B8C63DC7-7367-4210-853E-B7B004802EE4

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(2) If the termination of RSDI or SSI benefits occurred more than 12 months prior to the date of application or the termination was for medical reasons, a DDS determination of disability is required.

3. A determination of blindness by Division of Services for the Blind (DSB).

A HCWD applicant who alleges blindness and does not receive RSDI due to blindness must have their blindness determined by DSB unless a previous determination of blindness has been made. Follow procedures in MA-2531, Blindness M-AB policy for submitting materials to DSB if a determination is needed.

D. Medically Improved Cases

1. MAD Cases

a. If DDS determines during a Continuing Disability Review that an HCWD beneficiary in the Basic Group is no longer disabled, and still working, assume that the beneficiary is Medically Improved until the next recertification. b. At recertification do not refer a beneficiary in the Medically Improved Group to DDS for a determination of whether they still meet Medically Improved Criteria. To determine if the beneficiary continues to meet the Medically Improved eligibility criteria, contact the beneficiary’s treating physician using the DHB-5151, Health Coverage for Workers with Disabilities (HCWD) Medical Release Authorization and a DHB-5028, Authorization to Disclose Information forms asking the following three questions:

(1) Does the patient still has the underlying condition or conditions which made them disabled?

(2) Is the patient still under treatment for the condition or conditions which made them disabled?

(3) Is there a strong likelihood that the patient would again be disabled if they were to cease this treatment?

If the answers to all three questions are yes, the beneficiary continues to meet the Medically Improved criteria. Be sure to upload the document into NC FAST system.

If the answer to one or more of the questions is no, the beneficiary no longer meets the Medically Improved criteria. Evaluate eligibility in all other programs including the HCWD Basic Coverage Group. Docusign Envelope ID: B8C63DC7-7367-4210-853E-B7B004802EE4

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If the beneficiary would only be eligible as MAD/MAB/HCWD, a referral to DDS is required. Use the DDS referral form, DHB-4037 form for HCWD referrals.

2. MAB Cases When the local agency discovers that the beneficiary is no longer considered blind, refer to instructions in C.1. above.

E. Employment

1. Basic Coverage Group

Employment means being engaged in a substantial and reasonable work effort which is defined as the following:

a. Working in a competitive and inclusive work setting for a wage or salary, or being self-employed,

(1) Competitive means that the job was held open to the general public.

For example, a handyman who is hired by a neighbor to do a chore is not engaged in competitive employment. They may be self-employed if they meet that criteria.

(2) Inclusive means that the job is not in a sheltered workshop setting. Generally, those who work as staff in a sheltered workshop are not working in a “sheltered workshop setting.” Evaluate the beneficiary’s responsibilities to determine if their position is “sheltered.”

(3) Self-Employed has the same meaning as it is defined in MA- 2250, Income policy.

b. Being able to provide proof of payment of payroll taxes through FICA, or the equivalent.

For example, self-employed individuals who have not filed tax forms may submit alternative proof such as a business ledger, or similar documentation that shows that the business is operational.

2. Medically Improved Coverage Group

a. Employment

For a beneficiary to be considered “employed” for purposes of Medically Improved Group eligibility they must meet the Docusign Envelope ID: B8C63DC7-7367-4210-853E-B7B004802EE4

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requirements:

(4) Have gross earnings at least equivalent to those of an individual who is working 40 hours per month at minimum wage.

or

(5) Be actively engaged in a self-employment activity and have earnings after operational expenses at least equivalent to those of an individual who is working 40 hours per month at minimum wage.

b. Voluntary Loss of Employment

If a beneficiary in the Medically Improved Group voluntarily stops their employment, evaluate for eligibility in all other programs. If MAD is the only program in which they may be eligible, a disability determination by DDS is necessary. See section VII below for involuntary loss of employment.

F. Income

HCWD has varying income limits that determine eligibility and/or cost sharing. These limits are:

• Those who have unearned incomes greater than 150% of Federal Poverty Level (FPL) are not eligible for HCWD. • Those whose total countable income is equal to or less than 150% of FPL have no cost sharing (other than applicable co-payments).

• Those whose total countable income is greater than 150% of FPL must pay a $50 annual enrollment fee.

• Those whose total countable monthly income exceeds 200% of FPL must pay a monthly premium in addition to the enrollment fee. The monthly premium increases as income increases until countable income exceeds 450% of FPL, at which point the applicant/ beneficiary (a/b) must pay a full premium. The countable income determines whether the a/b is subject to cost-sharing and the amount thereof, countable income must be determined and all applicable exclusions applied.

Refer to MA-2252, Non- MAGI Medicaid Income/Reserve Limits chart.

Note: The a/b is to have work expense exclusions for the blind and impairment-related work expense exclusions for the disabled. Docusign Envelope ID: B8C63DC7-7367-4210-853E-B7B004802EE4

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G. Financial Responsibility

Apply financial responsibility and budgeting rules in MA-2260, Financial Eligibility Regulations – PLA policy.

V. ENROLLMENT FEE AND PREMIUM PROCEDURES

A. Enrollment Fee

All individuals with total monthly countable income above 150% of the federal poverty level must pay a $50 enrollment fee for each twelve-month certification period. The enrollment fee is collected by the county and retained to offset administrative expenses. Do not charge an enrollment fee for the retroactive month(s) when an a/b receives retroactive coverage. If a premium is due the local agency must mail the enrollment fee notice with the premium invoice.

Note: Members of federally recognized Native American tribes and Alaska natives are exempt from cost sharing, including enrollment fees and premiums.

1. Determine if an Enrollment Fee is due

a. Calculate the amount of total countable net income for the individual.

b. If this amount exceeds 150% of FPL, an enrollment fee is due. Those in this income range must have unearned income at or below 150% of FPL.

2. Notification of Enrollment Fee

Upon determination that an a/b is eligible for HCWD and that his income exceeds 150% of FPL, notify the applicant in writing that an enrollment fee of $50 is due. Refer to the DHB-5149, HCWD Enrollment Fee Notice form.

a. Give the a/b at least 12 calendar days to pay the fee.

b. If 12 calendar days exceeds the 45/90-day processing standard, pend until you receive notice of payment, or until the first workday after the due date for payment.

Allow for the exclusion of days when necessary verifications are received and the only remaining item necessary to process the application is the enrollment fee (and premium when applicable). The exclusion of days begins on the day of the request for the fee and ends on the day the fee is received or on the 13th calendar day, whichever occurs first. Use HCWD code for this purpose. Refer to MA-2300, Application policy. Docusign Envelope ID: B8C63DC7-7367-4210-853E-B7B004802EE4

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c. Inform the office or individual responsible for collecting the fee of the date by which the fee must be paid and the date when the caseworker must be informed of payment or nonpayment.

3. Payment/Collection/Notification

a. Each local agency is responsible for establishing procedures for collection of enrollment fees.

(1) Determine which methods of payment (i.e. cash, money order, certified check) are acceptable. Do not accept a non-certified check in payment.

(2) Partial payment is not allowed. The entire fee must be paid prior to approval of the application.

b. Determine what office and/or person(s) are responsible for collection of enrollment fees for HCWD. This decision must be communicated in writing to all eligibility staff responsible for HCWD determinations.

c. Establish procedures for communication between the caseworker and the fee collector for:

(1) Identification of case/individuals who must pay an enrollment fee, and

(2) The amount of the fee due, and

(3) The date by which the fee must be paid, and

(4) The time frame and method for notification to the caseworker that the fee has been paid, or

(5) Notification that the a/b refused to pay or failed to pay the fee by the date due.

d. The enrollment fee may be paid with funds provided by individuals or organizations other than the applicant, including county funds.

4. Decision Following Payment or Non-Payment

a. Upon receipt of notification from the fee collector that the enrollment fee has been paid, authorize eligibility.

b. Upon receipt of notification from the fee collector that the a/b refused to pay the fee or failed to pay the fee, deny the application. If it is a recertification, terminated after timely notice. Refer to MA-2420, Docusign Envelope ID: B8C63DC7-7367-4210-853E-B7B004802EE4

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Notice and Hearings Process policy for notices.

b. If no communication has been received from the fee collector on the first workday following the date on which the fee was due, contact the collection office/individual to verify payment status. If payment has not been made, document the contact and deny the application for non- payment of the fee. If it is a recertification, terminate after timely notice.

Note: If the recertification is late, provide coverage without enrollment fee payment until timely notice is effective.

5. Individuals Currently Receiving in Other Programs

Other than at application or recertification, an enrollment fee is not due.

B. Premiums

Applicants/beneficiaries with countable income above 200% of FPL must pay a monthly premium in addition to an enrollment fee of $50 per year. The premiums increase with income range until income exceeds 450% of FPL, at which point a 100% premium is due.

The 100% premium is based upon the average claims paid for an a/b receiving Medicaid and may change yearly.

Federal Poverty Level Income Range - HCWD Individual Monthly Premium Income Range - HCWD Couple Monthly Premium 0-150% $0 - 1,995 0 $0 – 2,705 0 151-200% $1,995.01 - 2,660 0 $2,705.01 - 3,607 0 201-250% $2,660.01 - 3,325 196 $3,607.01 - 4,509 265 251-300% $3,325.01 - 3,990 235 $4,509.01 – 5,410 318 301-350% $3,990.01 - 4,655 274 $5,410.01 – 6,311 370 351-400% $4,655.01 – 5,320 313 $6,311.01 – 7,213 423 401-450% $5,320.01 – 5,985 352 $7,213.01 – 8,115 476 451 and above $5,985.01 and up 875 $8,115.01 and up 875

Docusign Envelope ID: B8C63DC7-7367-4210-853E-B7B004802EE4

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2. Determine if a Premium is due.

a. Calculate the amount of total countable net earned and unearned income for the individual.

b. Those with unearned income above 150% FPL are not eligible for HCWD. c. If total countable monthly income exceeds 200% of FPL, a premium is due. Use chart above to determine premium amount.

Note: Members of federally recognized Native American tribes and Alaska natives are exempt from cost sharing, including premiums and enrollment fees.

3. Notification of Premium due:

Notify the a/b in writing that a premium is due by mailing DHB-5146, Health Coverage for Workers with Disability Premium Notice.

a. Date the premium invoice the date it will be mailed.

b. The invoice must identify the premium amount due for each month separately.

c. The caseworker must provide their name, direct phone number and email address on the invoice.

d. If an enrollment fee is due, mail the premium invoice with the enrollment fee notice.

e. Allow the a/b 12 calendar days to pay the premium. Day one is the day after the invoice is mailed.

f. Payment must be by certified check or money order payable to: “NC DHHS” and “HCWD Premium” must be written on the memo line of the check.

g. The payment must be mailed to:

DHHS Controller Office 2019 Mail Service Center Raleigh, NC 27699-2019

h. When the premium payment is made, North Carolina (NC) Medicaid will notify the county worker designated on the invoice by telephone and email a copy of the invoice and check to the Docusign Envelope ID: B8C63DC7-7367-4210-853E-B7B004802EE4

11

worker.

C. Premium Invoices for Application/Recertification/Change in Circumstance

1. Application process:

a. Prepare the DHB-5146, Health Coverage for Workers with Disabilities Premium Notice and ensure all premiums due from the first month authorized through one month after the current calendar month are included.

b. If 12 calendar days exceed the 45/90-day processing standard, do not dispose of the application until notice of payment has been received, or until the first workday after the due date for payment, whichever is earliest.

c. Allow for the exclusion of application processing days, when necessary, verifications are received and the only remaining item necessary to process the application is the premium (and enrollment fee when applicable).

d. The exclusion of days begins on the day of the request for premium payment and ends on the day the premium is received or on the 13th calendar day, whichever occurs first.

Refer to NC FAST Job Aid: Stop Processing Time.

Note: If pending for enrollment fee and premium(s), the end date is the later of the dates the enrollment fee or premium(s) is received. Continue to exclude days until both payments are received.

2. Retroactive Months

An applicant who requests retroactive coverage must pay a premium for each retroactive month authorized. An a/b cannot choose the month to which the premium is to be applied.

Note: No enrollment fee is due for retroactive months.

3. Recertification or Change of Circumstance ongoing cases:

a. Send the DHB-5146, Health Coverage for Workers with Disabilities Premium Notice on the first business day of the month prior to the next month of eligibility.

b. Allow the beneficiary 12 calendar days to pay the premium; day one is the day after the invoice is mailed.

Docusign Envelope ID: B8C63DC7-7367-4210-853E-B7B004802EE4

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c. Do not send a termination notice prior to the day after the payment is due.

C. Payment Status Verification and Procedures 1. When the DHHS Controller receives an HCWD premium payment, a staff member in the controller’s office notifies the Division of Health (DHB) Business Support Unit.

2. After being notified by the controller’s office of the premium payment, DHB staff will contact the caseworker on the same day with the premium payment information.

3. If no communication has been received from DHB on the 13th day after the premium invoice was mailed: a. Contact DHB Business Support by email at, Medicaid.BusinessSupport@dhhs.nc.gov to verify payment status.

b. Document the response from DHB and follow the appropriate steps (below) for approving or denying based on the response.

D. Premium Payment Received Procedures 1. Application process:

When DHB notifies the local agency caseworker that the HCWD premium has been received:

a. Refer to NC FAST Job Aid: Forced Eligibility for Income Support Medical Assistance, Special Assistance & Cash Assistance.

b. Authorize and activate a Medical Forced Eligibility PDC for the appropriate month(s).

c. If the applicant has identified the premium payment as an ongoing payment, apply the payment to the earliest unpaid ongoing month.

d. If the applicant has identified the premium payment as a retroactive payment, apply the payment to the earliest unpaid retroactive month.

e. If the payment is not identified as retroactive or ongoing, apply the payment to the earliest unpaid month.

Docusign Envelope ID: B8C63DC7-7367-4210-853E-B7B004802EE4

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2. Recertifications and Change of Circumstances ongoing cases:

When DHB notifies the local agency caseworker that the HCWD premium has been received:

a. Refer to NC FAST Job Aid: Forced Eligibility for Income Support Medical Assistance, Special Assistance & Cash Assistance.

b. Authorize eligibility for the month or months covered by the premium.

c. For ongoing cases, apply premium payments to the oldest unpaid month in the current certification period.

E. When The Premium Is Not Paid 1. Applications:

Upon receipt of notification from DHB that the a/b refused to pay the premium or failed to pay the premium:

a. Deny the application for failure to pay the premium and send the DHB-5147, HCWD Denial for Non-Payment of Premiums form.

b. Provide the coverage period and amount due for each month owed in the appropriate section of the DHB-5147 form.

c. Provide the caseworker’s name and contact information in the appropriate section of the DHB-5147 form.

d. If the enrollment fee has been paid, refund it.

2. Recertifications and Change of Circumstances for Ongoing Cases:

Upon receipt of notification from DHB that the a/b refused to pay the premium or failed to pay the premium:

a. Do not send a termination notice prior to the day after the payment is due.

b. Mail the DHB-5148, HCWD Termination for Non-Payment of Premium form, follow timely notice procedures found in MA-2420, Notice and Hearings policy. (1) Provide the coverage period and amount due for each month owed in the appropriate section of the termination Docusign Envelope ID: B8C63DC7-7367-4210-853E-B7B004802EE4

14

notice. (2) Provide the caseworker’s name and contact information in the appropriate section of the termination notice.

(3) For recertification, if the enrollment fee has been paid, refund it (do not refund enrollment fees in ongoing cases).

Note: When the recertification cannot be completed so that timely notification can be completed by the end of the current certification period, extend HCWD coverage on a month-by- month basis without a premium until timely notification procedures have been followed.

F. Program Classification

The classification code in NC FAST will be N, G, B or Q. Beneficiaries will be MAB/MAD-N, MAB/MAD-G, MAB/MAD-B or MAB/MAD-Q.

As for any Medicaid case, classification for HCWD is determined by income and resources. The HCWD beneficiary must be evaluated for dual eligibility (MQB-Q/MQB-B) if they are enrolled in Medicare.

Sub-Program Codes:

1. For the Basic Coverage Group, enter B1.

2. For the Medically Improved Coverage Group, enter M5.

E. Certification Period

1. Certification is for a twelve-month period.

2. HCWD applicants currently in other programs:

Where an HCWD applicant has less than twelve months left on an existing certification period, use the existing certification period for HCWD eligibility.

VI. RECERTIFICATION Complete a recertification every twelve months following procedures in MA- 2320, Recertification policy. The eligibility requirements in IV and V above continue to apply.

VII. CHANGE IN CIRCUMSTANCE Docusign Envelope ID: B8C63DC7-7367-4210-853E-B7B004802EE4

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A. 12 Month Continued Eligibility After Involuntary Loss of Employment

An HCWD beneficiary, who becomes unemployed for reasons beyond their control, including health reasons, continues to have eligibility in HCWD as if still employed for up to 12 months beginning the month following involuntary unemployment provided they:

1. Have received HCWD for at least one ongoing or retroactive month,

and

2. Maintain a connection with the workforce meaning: a. Registered with the Employment Security Commission for employment services,

b. Registered with a temporary employment agency,

c. Their employer considers the individual is on short-term disability even if they are not receiving a benefit, or

d. On sick leave.

3. Continues to meet all other eligibility criteria for HCWD.

B. Break in Eligibility

A beneficiary who has lost eligibility in either the Basic or Medically Improved Coverage Group may reapply in the Medically Improved Group.

VIII. TERMINATIONS

Follow procedures in MA-2352 Change in Circumstance, Terminations, And Reopening policy when beneficiary is ineligible for HCWD. Reminder, to evaluate for all programs prior to termination. Docusign Envelope ID: B8C63DC7-7367-4210-853E-B7B004802EE4

North Carolina Department of Health and Human Services North Carolina Medicaid Division of Health Benefits AGED, BLIND AND DISABLED MEDICAID MANUAL MA-2220

STATE RESIDENCY

1

REVISED 05/30/2023 – CHANGE NO. 09-23

Current Change Notice: 09-23 • Section II., Policy Principle: o Clarifies applicants/beneficiaries’ (a/b) to provide one (1) proof of state residency. This includes the revision of DHB-5097, Request for Information form which that the language Please note: You may need to provide up to two forms of verification for Proof of State Residency was removed. o Obsolete the DMA-5153, North Carolina Residency Applicant Declaration form and removed from the online form library. This form is no longer required due to the applicant is only required to provide one (1) proof of residence. o Moved Temporary Absence section from section III. to II. This provides instructions to the caseworker before denying or terminating an a/b Medicaid eligibility when temporarily absent. Also included, the beneficiary may be temporarily absent but returning to NC in less than 12 months. o Added Moved to Another State section to provide instructions for the caseworker. • Section IV. Residency Verification add: o Added a Homeless section pertaining to the local agency may accept self-attest from the a/b when they declare homeless. o A written declaration from a person who has a social, family, or economic relationship with the applicant and who has personal knowledge of the applicant's intent to live in North Carolina permanently may be accepted as proof of state residency. Obsolete DMA-5152 and revised to DHB-5152, North Carolina Residency Declaration. o Updated language pertaining to the local agency may deny eligibility on the 45th/90th day if there is substantial evidence showing that the documentation is false. • Section V. Individual Moving to NC was Previously Eligible in Another State o Request verification from the other state or send a DHB-5097 to the applicant to provide proof that the Medicaid eligibility in the other state was terminated. The caseworker may verbally contact the other state agency to verify Medicaid eligibility. The caseworker must document in the NC FAST the contact person’s name, title, and phone number. o Provide clarification and instructions when the applicant becomes eligible for NC Medicaid.

I. RESIDENCY REQUIREMENT

To receive Medicaid in North Carolina (NC), an applicant/beneficiary (a/b) must be a North Carolina resident and meet financial and non-financial requirements. This section outlines the specific requirements and how state residence is verified. In order to meet NC Medicaid residency requirements, an individual must:

A. Be physically present in NC and have the intent to reside here, or

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Intent to reside does not mean:

1. An intent to stay permanently or indefinitely in the state,

2. Nor does it require an intent to reside at a fixed address.

B. Have entered the state with a job commitment, or

C. Be seeking employment in NC.

II. POLICY PRINCIPLES

A. An applicant is required to provide one proof of NC residency.

1. Residency must be verified for all Medicaid applicants.

2. Residency shall not be verified during recertification.

• If there is a reason to believe a change in residency may have occurred, the caseworker may re-verify the address.

3. Review existing agency records, electronic sources, and Online Verification System (OVS) in NC FAST to verify the same address on the application before asking for verification.

4. There is no minimum requirement for the length of time an applicant must be physically present in NC.

B. Temporary Absence

1. Beneficiary:

The caseworker may not deny or terminate the beneficiary’s Medicaid eligibility when the beneficiary is temporarily absent from NC and intends to return to the state in less than 12 months. The caseworker must document in NC FAST.

During recertification, if there is a reason to believe a change in residency may have occurred, the caseworker may re-verify the address.

Example: At recertification, the caseworker reviewed the case, the beneficiary reported temporary absence and there were no other notes that the beneficiary returned to NC. The caseworker will re-verify the address.

2. Applicant:

3

The caseworker may not deny an application when an applicant who is temporarily absent from NC and claims to be a resident of NC. The applicant must verify residency before they can be considered temporarily absent for Medicaid purposes.

An applicant who is relocating to NC must establish NC state residency by the processing deadline. If NC residence is not established by the processing deadline, the application should be denied. Refer to V. below.

Example: The applicant is pregnant and applying for NC Medicaid. However, is temporarily located in Virginia and intends to return to NC, as a resident of NC. The applicant must verify NC residence to be determined eligible for NC Medicaid.

D. Moved to Another State

When another state has determined that the person is a resident there for purposes of Medicaid, the caseworker may deny or terminate the beneficiary’s Medicaid eligibility. Refer to MA-2252/3410, Change In Circumstance, Terminations, And Reopening policy.

III. EXCEPTIONS TO THE RESIDENCY DOCUMENTATION REQUIREMENT

In the following circumstances, no statement of intent or additional proof is necessary:

A. Incapable

An applicant who is incapable of stating intent to reside in NC is a resident of the state where they are physically located.

B. Institutionalized

An applicant who is institutionalized and capable of stating intent to reside in NC, is a resident of NC if they live in an institution in NC, and states intent to reside in NC.

C. Incarcerated

An individual who is incarcerated by the North Carolina Department of Public Safety, Division of Prisons, is deemed to have the intent to reside in North Carolina. Refer to MA-2510/3360 Living Arrangement policy.

IV. RESIDENCY VERIFICATION

A. Applicant/Beneficiary (A/B) Requesting Assistance

If the a/b requests assistance in obtaining documents needed for residency verification, it is the responsibility of the local agency to assist.

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B. Homeless

The caseworker may accept a written declaration (DHB-5152) from the a/b when they self-attest they are homeless. If the a/b does not have a mailing address to receive mail, the caseworker may use the local agency’s address and must document it in the NC FAST.

C. Electronic Online Verification

Review electronic sources, OVS in NC FAST or the existing local agency records to verify residency before asking the applicant to provide documents.

D. Unavailable Electronic Online Verification

When online verification is not available, the a/b may provide documentation that verifies their physical address. Send a DHB-5097/5097sp, Request for Information form requesting one of the following:

1. A valid North Carolina driver license or other identification card issued by the North Carolina Division of Motor Vehicles.

2. A current North Carolina rent or mortgage payment receipt, or current utility bill in the name of the applicant or the applicant's legal spouse showing a North Carolina address.

3. A valid North Carolina motor vehicle registration in the applicant's name and showing the applicant's current address.

4. A document showing that the applicant is employed in this State.

5. One or more documents proving that the applicant's domicile in the applicant's prior state of domicile has ended, such as closing of a bank account, termination of employment, or sale of a home.

6. The tax records of the applicant or the applicant's legal spouse, showing a current North Carolina address.

7. A document showing that the applicant has registered with a public or private employment service in this State.

8. A document showing that the applicant has enrolled the applicant's children in a public or private school or childcare facility located in this State.

9. A document showing that the applicant is receiving public assistance or other services requiring proof of domicile, other than medical assistance, in this State.

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10. Records from a health department or other health care provider located in this State showing the applicant's current North Carolina address.

11. A written declaration, completed DHB-5152, North Carolina Residency Declaration, Work First DSS-5276, North Carolina Residency Applicant Statement or DSS-5275 North Carolina Residency Declaration made under penalty of perjury from a person who has a social, family, or economic relationship with the applicant and who has personal knowledge of the applicant's intent to live in North Carolina permanently or for an indefinite period of time or that the applicant is residing in North Carolina to seek employment or with a job commitment.

12. Current North Carolina voter registration card.

13. A document from the U.S. Department of Veterans Affairs, U.S. Department of Defense, or the U.S. Department of Homeland Security verifying the applicant's intent to live in North Carolina permanently or for an indefinite period of time or that the applicant is residing in North Carolina to seek employment or with a job commitment.

14. Official North Carolina school records, signed by school officials, or diplomas issued by North Carolina schools, including secondary schools, community colleges, colleges, and universities verifying the applicant's intent to live in North Carolina permanently or for an indefinite period of time or that the applicant is residing in North Carolina to seek employment or with a job commitment.

Refer to Job Aid: Verifying North Carolina Residency

E. Verification for Other Households Members

1. For a child, accept verification of the residence of the parent or caretaker if they live together.

2. For any of the documents in section IV.D. above, also accept documentation of the address of the spouse or the parent/caregiver if they live together.

F. Deny Eligibility on the 45th/90th Day

The caseworker may deny eligibility on the 45th/90th day, if there is substantial evidence showing that the documentation is false. If reasonably necessary, the caseworker must send DHB-5097/5097sp to request additional documentation to verify residency.

V. INDIVIDUAL MOVING TO NC WAS PREVIOUSLY ELIGIBLE IN ANOTHER STATE

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A. If an applicant was receiving Medicaid in another state prior to moving to NC, the local agency is responsible for contacting the prior state to:

1. Notify the state of the applicant’s move to NC, and

2. Request verification from the other state or send a DHB-5097/5097sp to the applicant to provide proof that the Medicaid eligibility in the other state was terminated.

The local agency may verbally contact the other state agency to verify Medicaid eligibility. The local agency must document in NC FAST the contact person’s name, title, and phone number.

3. Follow-up with the out-of-state agency at least every 2 weeks until a response is received either verbally or written. If not verified by the 45/90 day, or after 2 requests, whichever is later, deny the application. Document in NC FAST all attempts to contact the out of state agency as well as the response received.

4. The local agency may obtain any information on resources such as bank accounts, stocks, bonds, promissory notes, former homesite, etc., that will aid in determining eligibility in NC.

B. Medical Bills

1. If the applicant has outstanding medical bills in NC in the same month the applicant received Medicaid in the other state, verify whether the other state’s Medicaid program will cover bill(s) incurred in NC.

• Some Medicaid programs in other states are similar to NC. They only cover out-of-state services if it is an emergency, or the service was prior approved.

2. If the applicant has a bill in NC that will NOT be covered by the other state, authorize Medicaid in NC if otherwise eligible for that month.

C. If the other state will pay the NC claims:

1. Contact the medical provider(s) and verify whether they are enrolled or are willing to enroll with the other state.

2. If providers are not willing to enroll and file claims with the other state, authorize NC Medicaid, if otherwise eligible.

3. If providers are willing to enroll and bill the other state, there is no need for NC coverage for that month(s).

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D. If eligible for NC Medicaid

1. Verify when the out-of-state Medicaid coverage was terminated, and

2. Authorize North Carolina Medicaid in the following eligibility month or based on C. above

3. Document in the NC FAST.

North Carolina Department of Health and Human Services Division of Medical Assistance Medicaid Eligibility Manual AGED, BLIND, AND DISABLED MEDICAID MANUAL MA-2221

COUNTY RESIDENCE

1 MA-2221 COUNTY RESIDENCE REVISED 08/01/09 – CHANGE NO. 12-09

I. POLICY RULES

A. An individual applies for Medicaid in his county of residence.

County residence is not an eligibility requirement. When it is discovered that an individual is a resident of another county, do not deny an application. The county must continue to process and transfer to the correct county following procedures in this section.

B. If a recipient moves to another county, transfer the case to the new county of residence.

II. DETERMINING COUNTY RESIDENCE

A. Non-institutional Living Arrangement

An individual has residence in the county in which he lives. This applies even if the individual owns a home in a different county or state.

B. Institutional Living Arrangement

An individual in a hospital, mental institution, nursing facility (SNF, ICF-MR), Adult Care Home (rest homes/domiciliary care facility/assisted living) or a similar institution/facility:

1. Is a resident of the county in which he lived immediately prior to entering the facility.

2. If an individual moves from another state directly into an institutional living arrangement, the individual is a resident of the county in which the facility is located. If the individual moves to more than one institution/facility, the county of residence is the county where the first institution/facility is located.

NOTE: Residence in an adult care home does not establish county residence, even when the individual was a private paying adult care home resident. Establish his county of residence prior to entering the adult care home.

AGED, BLIND, AND DISABLED MEDICAID MANUAL Transmitted by Change No. 09-05

MA-2221

COUNTY RESIDENCE 12-01-04

2 REISSUED 08/01/09-CHANGE NO. 12-09

(II) C. Temporary Absence From County/Home

Temporary absence from the county of residence, with subsequent return or intent to return, does not change the residence, unless another county has determined that the person is a resident there.

1. An individual may be temporarily absent from the home without interruption of the continuity of Medicaid. If it is discovered that an individual is not temporarily absent, evaluate county of residence following instructions in.A. or B. above.

2. Reason for temporary absence from the county/home include but are not limited to:

a. Visits to friends/relatives in another county: If the visit exceeds three months, the caseworker verifies the following:

(1) Whether the recipient intends to return home. Request a signed statement from the client which states intent to return home, and

(2) Verification that rent/house utility payments are being made, and

(3) Receipt of mail continues.

b. Reason for continuing absence: Request assistance from the second county to document the reason for continued absence.

Reasons for continued absence include, but are not limited to:

(1) Illness of the recipient.

(2) Illness and need for continuing care of someone the recipient had been visiting in another county.

North Carolina Department of Health and Human Resources AGED, BLIND, AND DISABLED MEDICAID MANUAL MA-2221

COUNTY RESIDENCE

3 07/01/04 (II.) D. Individual With No Permanent Address

A person with no fixed or permanent address is a resident of the county where he states his intent to remain. If the individual is incapable of stating his intent to remain, he is a resident in the county in which he is found.

E. Disputed County of Residence

If the county of residence is disputed, counties should contact their Medicaid Program Representative (MPR) for settlement. The county in which the applicant files the application must proceed to process the application without delay. Upon review of all facts in the case, the MPR(s) will notify the counties of the decision regarding residence.

If the county, which processed the application, is not the county of residence, then that county should immediately contact the Claims Analysis Section of DMA.

Additionally, the county should identify any claims charged in error to their county by reviewing the "Recipient Payment Register." Once claims are identified, notify the Claims Analysis Section of DMA in writing of the charges. Include the recipient's name, individual identification number, and dates of service.

NOTE: This is different from the situation in which a county took a courtesy application and the county of residence refuses to accept the application. For this situation, see MA-2300, Initial Contact.

III. VERIFYING THE COUNTY OF RESIDENCE

A. Accept the client's statement as verification unless there is reason to doubt it.

B. If there is reason to doubt the client's statement, verify using following sources:

1. Home visit/collateral contacts

2. Real and personal property tax records

3. Motor vehicle registration

4. Driver's license, i.e., address

5. Order of custody/placement responsibility by the court.

An individual who recently moved may not have had time to update these items. Evaluate each situation based on its individual circumstances.

North Carolina Department of Health and Human Resources AGED, BLIND, AND DISABLED MEDICAID MANUAL MA-2221

COUNTY RESIDENCE

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IV. APPLICANT MOVES FROM ONE COUNTY TO ANOTHER

A. Policy Rules

1. Do not transfer an application to another county.

If an application is denied or withdrawn, no further action is necessary.

2. Once the application is approved, transfer the ongoing case according to procedures in V.

3. The county that took the application is financially responsible for all eligible months beginning with the retroactive period until the transfer effective month for the active case.

4. When there is a pending application in more than one county, use the first date of application. The county that took the first application is responsible for processing.

B. Verification of Move

1. When an individual reports he has moved to another county, document the new address, phone number, and county of residence. Update this information in EIS when the case is approved.

2. When the county learns from another source that an applicant has moved, send a DMA-5097, Request for Information, asking the applicant to verify the new address.

3. If the applicant does not respond, send a second DMA-5097, Request for Information. If no response, follow instructions in MA-2304, Processing the Application.

4. If the applicant has moved, but left no forwarding address, follow procedures in MA-2304, Processing the Application, to determine a current address.

C. Responsibility of the Second County to Assist

1. Each agency must appoint a contact person(s) to handle all mail and phone inquiries regarding applicants that move to another county.

2. The contact person in the first county may request assistance from the second county in locating an applicant that has moved to the second county and/or obtain information necessary to determine eligibility.

North Carolina Department of Health and Human Resources AGED, BLIND, AND DISABLED MEDICAID MANUAL MA-2221

COUNTY RESIDENCE

5 (IV.C.) 3. The contact person in the second county must make a reasonable effort to contact the applicant and/or obtain necessary information/verification.

4. The contact person in the second county must respond to the contact person in the first county within two workdays of the request for assistance.

D. Disputes

In the case of a dispute between counties concerning the responsibility for delay in processing, contact your Medicaid Program Representative (MPR). The MPRs for the respective counties will determine which county is responsible for the delay based on the policy set forth above. The documentation of the contact persons is used to make the determination.

V. COUNTY REASSIGNMENT OF ONGOING CASES

When a recipient in an ongoing case moves from one county to another, his Medicaid eligibility must continue without a break in coverage provided he continues to meet all eligibility criteria.

A. First County Responsibility When Learning of Client’s Move or Plan to Move

1. If the client plans to move to another county, explain to the recipient his responsibility to notify the IMC in the first county when he actually moves.

2. Upon notice of the actual move to another county, inform the a/r, verbally when possible, and by transfer letter, of the agency’s responsibility to continue assistance if eligibility exists.

Also, advise the a/r of his responsibility to contact the first county immediately to report any changes in the household that may affect Medicaid eligibility such as income and/or household composition. The first county must react to all changes reported before the transfer is complete.

B. Case Status

Prior to keying a county transfer, always check the certification period. Also, check to see if there are other Medicaid cases for the household, including the Family and Children’s Medicaid Program. If a review is due, do not complete the transfer until the review is completed.

1. Authorized case

a. If a review is due, the first county must complete the review and authorize for the next certification period, then reassign the case to the second county.

North Carolina Department of Health and Human Resources AGED, BLIND, AND DISABLED MEDICAID MANUAL MA-2221

COUNTY RESIDENCE

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(V.B.1.a.) EXAMPLE: The transfer effective month is February. The certification period is August - January. The first county must complete the review prior to transfer.

b. If a review is due in the month the transfer is effective or later, the second county must complete the review and authorize for the next certification period.

EXAMPLE: The transfer effective month is October. The certification period is July – December. The second county must complete the review and authorize for the next certification period.

c. If the first county transfers a case to the second county with an expired certification period, the first county is still responsible for completing the review. Once the review is completed, the first county should send the second county the review to authorize the next certification period in EIS.

EXAMPLE: The transfer effective month is July. The certification period expired in June. The first county must complete the review and send the review to the second county to authorize for the next certification period in EIS.

2. Deductible case

a. If the deductible has been met by the time of the notification of the move, follow procedures in 1. above.

b. If the deductible has not been met at the time of the move, always check the certification period. Complete the review if needed and then complete the county transfer.

c. If and/or when the first county receives notification and verification from the second county that the deductible was met during the first county's responsibility, the first county authorizes assistance on a DSS-8125 for its period of responsibility only.

C. Effective Date of County Transfer

1. The effective date of the county transfer may be no earlier than the second month following completion and mailing of the transfer letter. At a minimum, the first county will continue assistance for one month following the keying of the transfer.

2. Transfer the case in EIS effective the second month following the month of input.

North Carolina Department of Health and Human Resources AGED, BLIND, AND DISABLED MEDICAID MANUAL MA-2221

COUNTY RESIDENCE

REVISED 11/01/11 – CHANGE NO. 17-11

(V.C.2.) EXAMPLE: On October 18 the recipient notifies the first county of a move to the second county. The certification period is checked to determine if a review is due. The certification period ends in February. The transfer letter is mailed on October 26. The county transfer is keyed on the same day. The transfer is effective December 1.

3. You may key a county transfer through the last working day of the month.

4. Managed Care coverage is automatically terminated by EIS on the last day of the month prior to the ongoing month. See EIS 3500, Transfers for Active Cases.

D. Completing the Transfer Letter

Complete the DMA-5154, County Transfer Letter, on the same day that the county transfer is keyed.

1. Give the original to the client if he is in the agency or mail if notification was by telephone call or letter.

2. Send a copy of the transfer letter, along with a copy of the most recent case profile to the second county.

3. File a copy in the eligibility record.

E. Entering a Facility After Reporting Move to Another County

If a recipient moves to another county in a private living arrangement and then enters an institution/facility in the second county prior to the effective date of the county transfer, continue the county transfer as proposed.

F. Medicaid ID Cards

1. A change in the recipient’s address alone will not result in issuance of a new Medicaid ID card. However, if the individual is enrolled in Carolina Access/Community Care of North Carolina, his primary care provider (PCP) will likely change when he changes counties. After the new PCP information in entered into EIS, the individual will be issued a new Medicaid card with the revised PCP information as well as the recipient’s new address.

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North Carolina Department of Health and Human Resources AGED, BLIND, AND DISABLED MEDICAID MANUAL MA-2221

COUNTY RESIDENCE

8 REISSUED 11/01/11 – CHANGE NO. 17-11 (V.F.)

2. The first county is responsible for mailing a returned Medicaid card, with the recipient’s old address, directly to the recipient.

3. If the client does not receive the ID card during the transfer process and it has not been returned to the first county, request a replacement if his name is on the ID card register. Refer to MA-2380, Medicaid Identification Card, for issuing a replacement card.

G. Second County Responsibility

1. If a recipient notifies you of a move from another county, but has no transfer letter, notify that county immediately. Verify the assistance status in that county. Work with the first county in determining if a review is due. Assist the county and the client in completing the review and transfer.

2. Upon receipt of the transfer letter: