STATE/COUNTY SPECIAL ASSISTANCE MANUAL North Carolina Division of Social Services Special Assistance Program Revised: June 1, 2026

State/County Special Assistance Program

www.ncdhhs.gov/divisions/social-services

820 S. Boylan Avenue, Raleigh, NC

Mailing address: 2401 Mail Service Center

Raleigh, NC 27699-2401 NCDHHS is an equal opportunity employer and provider.

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STATE/COUNTY SPECIAL ASSISTANCE MANUAL

TABLE OF CONTENTS

• SA-3100 ELIGIBILITY REQUIREMENTS • SA-3110 APPLICATION PROCESS • SA-3200 RESOURCES • SA-3205 TRANSFER OF RESOURCES • SA-3210 INCOME • SA-3220 BUDGETING PRINCIPLES • SA-3240 CITIZENSHIP AND IDENTITY • SA-3300 ADMINISTRATION OF BENEFITS • SA-3310 CHANGES IN CIRCUMSTANCE • SA-3320 REDETERMINATION OF ELIGIBILITY • SA-3330 NOTICES • SA-3340 HEARINGS • SA-3400 AUTOMATED INQUIRY AND MATCH PROCEDURES • SA-3410 RECIPIENT FRAUD • APPENDIX C – SPECIAL ASSISTANCE TO THE CERTAIN DISABLED (SCD)

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STATE/COUNTY SPECIAL ASSISTANCE MANUAL SA-3100 ELIGIBILITY REQUIREMENTS North Carolina Division of Social Services Special Assistance Program Revised: June 1, 2026

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STATE/COUNTY SPECIAL ASSISTANCE MANUAL SA-3100 ELIGIBILITY REQUIREMENTS

TABLE OF CONTENTS

I. Introduction

II. General Eligibility A. Basic Requirements B. SSI Beneficiaries C. Non-SSI Beneficiaries D. NC Innovations Waiver and Special Assistance E. SA and PACE Cannot Be Received At The Same Time

III. Age and Disability Eligibility Requirement A. SAA (Special Assistance for the Aged) B. Verification of Date of Birth for SAA C. SAD (Special Assistance for the Disabled)

IV. State Residence Requirement A. Residence in North Carolina Voluntarily with Intent to Remain B. Verification C. Date of Application and Eligibility D. Exception to the 90-Day Residency Requirement

V. Licensed SA Approved Facilities A. Adult Care Homes (ACHs) B. Family Care Homes C. Adult Care Home Beds in Nursing Facilities and Hospital Facilities D. Residential Hospice Facilities E. Certain Mental Health Facilities Licensed Under G.S. 122C

VI. Conflict of Interest A. General Statute 108A-47 B. Contact for Questions Regarding NCGS 108A-47

VII. Valid FL-2 Requirement – Level of Care A. Applications B. Ongoing Cases C. Additional Requirements for Special Care Unit Payments at the

Enhanced Rate

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D. Requirements for Enhanced Rate Payments for SAIH Beneficiaries

with a Diagnosis of Alzheimer’s Disease or Dementia

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I. INTRODUCTION

State/County Special Assistance (SA) is a Supplemental Security Income (SSI)

state supplement that pays cash benefits to eligible beneficiaries who reside in

licensed facilities authorized to receive SA payments. The SA payment is funded

by 50% county dollars and 50% state dollars. SA beneficiaries are automatically

eligible for Medicaid. Effective January 1, 2023, SAIH beneficiaries are also automatically eligible for Medicaid.

To be eligible for SA, an individual must be eligible for SSI, or ineligible for SSI

solely due to being over income for SSI. Each applicant/beneficiary (a/b) for State/County Special Assistance must apply for all benefits to which he/she may be entitled, including receiving the maximum benefit for which the applicant is eligible. This includes, but is not limited to, SSI. If the a/b’s income is less than the Federal Benefit Rate (FBR) for SSI, after applying appropriate income exclusion up to $20, the a/b is required to apply for SSI. See SA-3110, Application Process.

This section outlines basic eligibility requirements for the receipt of Special

Assistance.

Note: Throughout SA policy any references to the a/b, always apply to the

a/b’s Authorized Representative as well.

II. GENERAL ELIGIBILITY

A. All beneficiaries must meet the following requirements:

1. Be an individual who is age 65 or older; or is 18-64 and disabled or

legally blind; or an individual who is under 18 and is legally blind.

2. Reside in North Carolina with the intent to remain and meet residency requirements.

3. Reside in a licensed facility authorized to receive SA payments, except

for temporary absence not expected to exceed 30 days.

4. Require the level of care provided in licensed adult care homes or supervised living and have a valid FL-2 that is signed and dated by a physician, physician assistant, or nurse practitioner.

5. Not be an inmate in a jail or prison.

6. Receive SSI or are financially ineligible for SSI solely due to being over income for SSI.

7. Be a U.S. citizen or qualified alien.

SA-3100 I–II.

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B. SSI Beneficiaries

A current SSI beneficiary automatically meets the categorical and financial

requirements for SA.

C. Non-SSI Beneficiaries

To receive SA, non-SSI beneficiaries must meet the eligibility

requirements for SSI except for income. In addition, non-SSI beneficiaries

must meet the following requirements:

1. Provide documentation of U.S. citizenship or a qualified alien status.

Refer to SA-3240, Citizenship and Identity.

2. Provide documentation of identity. Refer to SA-3240, Citizenship and Identity.

3. Meet the SA income requirements. Refer to SA-3210, Income.

4. Meet resource requirements. Refer to SA-3200, Resources.

5. Not have made a non-allowable transfer of resources (or established a

non-allowable trust). Refer to SA-3205, Transfer of Resources.

D. NC Innovations Waiver and Special Assistance

Depending on individual circumstances and need, an individual can

potentially receive both Community Alternatives Program (CAP) via the

NC Innovations Waiver and SA in an ACH (or SAIH) at the same time if

they reside in a 5600C Supervised Living facility that is licensed and

eligible to receive SA payments (and which is acceptable per the CAP

Innovations program). The client must still meet all eligibility criteria for SA

as outlined in the SA policy manual.

CAP services via the NC Innovations Waiver are the only type of CAP

services that a Special Assistance or SAIH beneficiary may receive.

E. SA and PACE Cannot Be Received At The Same Time

Individuals who receive Special Assistance cannot receive NC Program of

All-Inclusive Care for the Elderly (PACE) coverage at the same time, as

PACE provides all-inclusive care.

When an active PACE recipient applies for Special Assistance, the PACE

recipient must disenroll from PACE by the end of the SA application

processing time standard (45th/60th day) and meet all other SA eligibility

criteria in order for the SA application to be approved. SA-3100 II.

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• If the individual has not been disenrolled from PACE by the 45th/60th day, the SA application must be denied.

• If the PACE recipient has been disenrolled from PACE by the 45th/60th day of the SA application and meets all other SA eligibility criteria, the effective date of SA benefits cannot be on or prior to the PACE disenrollment date.

• “Disenrolled” refers to all parts of the PACE disenrollment being completed, with an effective end-date for PACE in NC FAST.

Important: For any month in which an SA payment is received while the

SA beneficiary is also enrolled in PACE, that SA payment

is an overpayment which must be recouped. There can be

no overlap of SA and PACE services.

III. AGE AND DISABILITY ELIGIBILTY REQUIREMENT

A. SAA (Special Assistance for the Aged)

Be age 65 or older.

B. Verification of date of birth for SAA is required.

1. Verify applicant’s age by SOLQIS.

2. If the applicant’s age cannot be verified by SOLQIS or OLV and is not

questionable, accept applicant’s statement.

3. If applicant’s age cannot be verified by SOLQIS or OLV and the

applicant’s statement of age is questionable, any one of the following

sources can be used.

a. Birth certificate issued by a governmental body, or

b. Hospital records established at time of birth (including a hospital-

issued birth certificate).

4. If neither of the verification documents are available and the

applicant’s statement of age is questionable, use any two of the

following documents:

a. Driver's license b. Marriage license c. Family Bible records SA-3100 III.

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d. Church documents such as baptismal or confirmation records e. Passport f. Military records g. School records h. Department or institution records i. Court records, including adoption records j. Immigration records k. Naturalization records l. U.S. census records m. Witnessed statement from an individual having specific knowledge

about the age of the a/b including:

(1) The name of the child;

(2) Date and place of birth;

(3) Name of father;

(4) Maiden name of mother;

(5) Why the verification is needed;

(6) A signed statement authorizing release of the information.

Other Verification Sources for Age

1. Individuals born in NC:

a. NC Vital Records

1903 Mail Service Center

Raleigh, NC 27699-1903

OR

b. The County Health Department where the individual was born. For

individuals born in other states, contact the state vital records

office to determine what agency to contact for birth verification.

2. Verification of age of children born to U.S. citizens who were in

overseas governmental services may be accomplished by contacting:

Office of Authentications U.S. Department of State CA/PPT/S/TO/AUT 44132 Mercure CIR PO BOX 1206 Sterling, VA 20166 1206 Telephone: 202-485-8000 SA-3100 III.

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C. SAD (Special Assistance for the Disabled)

1. Be age 64 and under, and

2. Be determined permanently and totally disabled or legally blind by

Social Security standards. Refer to SA-3110, Application Process for

procedures to establish disability for applicants who have not had

disability or blindness established.

3. If under 18 the a/b must have established that he/she is legally blind.

The child or adolescent must reside in a specialized community

residential center. A child or adolescent is eligible to receive SA in a

specialized community residential center only until he/she turns 18.

When he/she becomes 18, he/she may be eligible for SA in an adult

care home or other adult SA facility if he/she continues to meet all

other SA requirements.

IV. STATE RESIDENCE REQUIREMENT

A. An individual must be residing in North Carolina voluntarily

with intent to remain.

1. To be eligible for SA, the individual must be a resident of North Carolina for at least 90 consecutive days immediately prior to

receiving this assistance. See IV. D. below for only exception.

2. When an individual moves into North Carolina, and states his or

her intent to remain, a written statement of intent must be

obtained.

3. An individual visiting in the state without a stated intent to remain

is not considered a North Carolina resident.

4. An applicant cannot declare an intent to remain in North Carolina

and sign an intent to return home to exclude their home site in

another state. Refer to SA-3200, Resources, for information on

intent to return.

B. Verification

If the applicant’s statement of residency is questionable, obtain one of the

following documents for verification: SA-3100 III–IV.

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1. Post-marked letters 2. Public utilities records or credit accounts records

3. Voter Registration Records

4. Rental records 5. Real property ownership records 6. Employment records

7. Other documentary evidence presented by the applicant. (Example:

whether applicant has their belongings in this residence)

C. Date of application and eligibility

1. If the applicant applies before the 90-day requirement is met, the a/b

is not eligible for SA. Deny the application and document the date the

applicant moved to North Carolina (with the intent to remain) and when

the 90th day of state residency will be met, unless the 90-day

requirement can be met during the processing time. The application

may be approved if the residency requirement will be met during the

application processing time frame and if all other eligibility criteria are

met. The SA benefit cannot be authorized prior to the applicant

meeting residency requirements.

2. If an applicant applies on or after the 90th day of state residency, the

a/b is eligible for SA effective the day all other eligibility requirements

are met. If the 90th day falls after the first day of the month, authorize

a partial payment for that month, prorated from the 90th day of state

residency, even if the applicant was in an SA facility on the first day of

that month. A Special Assistance payment cannot be made for any

days in an SA facility during the waiting period. The effective date for

retroactive payments cannot be earlier than the 90th day of residency

in the state. As always, when computing a partial payment, include the

full personal needs allowance, but do not count the applicant’s income

for that month.

3. Ask the a/b when he/she voluntarily moved and decided to remain in

North Carolina to determine the 90th day of residency. Beginning with,

and including the date of intent to remain, count forward 90 days (or

add 89 days to the date of intent to remain). Payment may begin

effective the 90th day, if all other eligibility criteria have been met.

D. Exception to the 90-day residency requirement:

When the applicant is discharged from a State facility who was a patient in the facility because of an interstate mental health compact.

SA-3100 IV.

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1. There is no 90-day waiting period for applicants who meet this

criterion. The state facility discharging the applicant must provide the

county DSS with verification that the applicant was a patient in the

state facility on a DMA-5010, Referral for Inpatient Hospital and

Intermediate Care Facilities.

2. For purposes of this provision in the law, a state facility is a facility

listed under G.S.122C-181. This includes the three state psychiatric

hospitals (Cherry, Central Regional, Broughton); the three regional

developmental centers (Caswell, Murdoch, J. Iverson Riddle); the

three alcohol/substance abuse centers (Julian F. Keith, R.J. Blackley,

Walter B. Jones); Whitaker Psychiatric Residential Treatment Facility;

and the neuro-medical treatment centers (Black Mountain, O’Berry,

Longleaf).

3. A person who was a patient in a state facility because of an interstate

mental health compact arrangement and who is discharged from the

state facility directly into an SA facility becomes a legal resident of the

county in which the SA facility is located.

V. LICENSED SA APPROVED FACILITIES

To receive SA, an a/b must reside in a licensed facility authorized to receive SA payments, except for temporary absence not expected to exceed 30 days.

Civil Rights Agreement: all facilities accepting SA residents must have a Civil Rights Agreement, DSS-1464-(ia) signed by the facility owner or operator on file with the NC Division of Social Services (DSS). Once verified by the DHHS Special Assistance section, NC FAST will reflect on the Facility Inquiry screen that a facility has a valid Civil Rights Agreement. Combination nursing facilities and hospitals (with adult care beds) for Medicare and Medicaid Certification must have signed these agreements and submitted them to the Centers for Medicare and Medicaid Services as a requirement of licensure. If the facility shows “Medicaid Certified”, it meets the criteria for the Civil Rights Agreement.

Verification of Facility Record in NC FAST: Verify in NC FAST that the facility is an SA eligible facility by utilizing Facility Search. Click on the facility in Search results to view the Facility Inquiry screen. There will be a “Y” in the SA Eligible Indicator for the facility if it is a facility approved to accept SA. Print the NC Fast Facility Inquiry results for the facility that is the a/b’s physical residence. Use the printed NC FAST Facility Inquiry screen to verify/document the facility’s correct name, physical location, licensure status, facility code and other important eligibility data. The IMC must obtain and file the Facility Inquiry screen printout in the SA case record to show verified facility eligibility at every application, recertification, and any a/b change/move to a new facility residence.

SA-3100 IV–V.

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The following facility types may accept Special Assistance:

A. Adult care homes (ACHs)

B. Family care homes

C. Adult care home beds in some nursing facilities and hospital facilities (combination facilities). NC FAST will only allow one facility type to display. If the facility is a combination/dual facility, it will display “Nursing Home” on the Facility Search Screen rather than “domiciliary.”

D. Residential hospice facilities

E. Certain mental health facilities licensed under G.S. 122C

1. A facility, designated with the letter “A” which serves adults whose primary diagnosis is mental illness, but who may also have other diagnosis. This facility type is designated in NC Administrative Code 10A NCAC 27G.5600.

2. A facility, designated with the letter “C” which serves adults whose primary diagnosis is a developmental disability, but who may also have other diagnoses. This facility type is designated in NC Administrative Code 10A NCAC 27G.5600.

3. Facilities known as Specialized Community Residential Centers designated in NC Administrative Code 10A NCAC 27G.2100. In this group, only mental health facilities with a designation of 27G.2101 for children and adolescents under age 18 are SA eligible facilities. Facilities which are ICF/MR are not eligible for SA funds. (Only children and adolescents underage who are legally blind are eligible for SA.)

4. Licensed facilities listed by type are found on the Division of Health

Service Regulation website.

VI. CONFLICT OF INTEREST

A. General Statute 108A-47

North Carolina General Statute 108A-47 prohibits payments of Special

Assistance to any person residing in an adult care home that is owned or

operated, in whole or in part, by any of the following:

SA-3100 V–VI.

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1. A member of the Social Services Commission, any county board of

social services, or any board of county commissioners;

2. An official or employee of the Department, unless the official has

been appointed temporary manager of the facility pursuant to NCGS

131E-237, or of any county department of social services; (“County

department of social services" means a county department of social

services, consolidated human services agency, or other local agency

designated to administer Special Assistance.)

3. A spouse of any person in (1) or (2).

B. Contact for Questions Regarding NCGS 108A-47

If your county agency has any questions regarding this provision, or if a situation exists in your county that may violate this provision, please contact a Special Assistance Representative via DSS-9000SA to the SA listserv at specialassistance@dhhs.nc.gov.

VII. VALID FL-2 REQUIREMENT - LEVEL OF CARE

To receive SA, in an adult care home or for Special Assistance In-Home, the a/b must have a valid Adult Care Home FL-2. A legible copy of the FL-2 must be placed in the eligibility record. FL-2’s are valid for 12 months. Also, refer to SA-3110, Application Process.

A. Applications

1. At application the FL-2 must be dated no more than 90 calendar

days prior to the date of application to be considered valid if the

applicant is not already a resident of an SA facility.

2. If the applicant resides in an SA facility prior to the date of the SA

application, and has a valid FL-2, the FL-2 cannot be dated more

than 12 months prior to the processing deadline for the SA

application. If the FL-2 will be over 12 months old by the end of the

processing deadline, the Income Maintenance Caseworker (IMC)

must request an updated FL-2 via the DHB-5097 12 calendar days

before the FL-2 becomes invalid.

3. When an FL-2 form is submitted as level of care verification, the IMC must thoroughly examine the FL-2 to determine if it is valid. The minimum requirements for an FL-2 to be considered valid are:

a. It must be legible.

SA-3100 VI–VII.

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b. It must be signed and dated by a physician, physician assistant, or nurse practitioner.

c. The a/b’s name, date of birth, attending physician’s name and address or Practice name and address (whichever is applicable), and admitting diagnosis must be indicated on the FL-2.

d. The Recommended Level of Care must be indicated in the Recommended Level of Care field on the FL-2.

e. The Recommended Level of Care field must indicate the need for Domiciliary care, which is a term that includes care provided in ACHs, assisted living, family care homes, supervised living, mental health group homes, hospice residential facilities, rest homes, or specialized community residential centers. Any of these terms or “Domiciliary”) are acceptable if written in the Recommended Level of Care field on the FL-2.

f. The Adult Care Home FL-2 (DMA-372-124-ACH) is posted

on the DMA Forms website and should be used for SAIH

cases.

g. An electronic FL-2 or NC Medicaid Long Term Care FL-2 can also be accepted as long as the form contains, at a minimum, the items listed in a - e above. (Note that the Recommended Level of Care field may be labeled as the “Requested Level of Care” on the NC Medicaid Long Term Care FL-2 and on some Electronic FL-2s. Domiciliary or one of the approved terms in A.3.e. above must still be clearly checked or written in under the “Recommended” or “Requested” Level of Care.)

h. If the FL-2 form presented to the IMC is invalid due to missing

information and/or needs correction, explain that the original

physician/physician assistant/nurse practitioner who signed the

FL-2 can correct the form by completing the blank or incorrect

boxes and adding their initial and date by each correction.

Note: No one other than the medical originator who initially

completed the FL-2 can alter the information on the FL-2.

(Exception: If the physician, physician assistant, or nurse practitioner completing the FL-2 leaves off the address of the physician or practice, the IMC is allowed to verify the correct address and add the address to the FL-2. The IMC must document when/who/how the address was verified.)

SA-3100 VII.

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i. A valid FL-2 which meets all the requirements listed above is

required for SA Basic, SA SCU, SAIH and the SAIH / TCL

program.

4. SA benefits can begin no earlier than the date the FL-2 is

appropriately signed for an adult care home SA case. (For SA In-

home cases see SA-5200.) The FL-2 must be received during the

application processing time standard.

5. Be mindful that any information provided on an FL-2 may provide

eligibility leads or leads on situation changes that need further

exploration. It is the county’s responsibility for assuring all leads are

followed up.

6. Ensure that the date of the FL-2 is recorded correctly in the

Certification Start Date field of Level of Care Evidence in NC FAST.

7. Assignment of the correct SA rate in NC FAST requires that the

correct Level of Care Type is selected in Level of Care evidence on

the NC FAST dashboard. For each placement type (facility, SA In-

Home, and TCL) there is both a “Basic” and an “Enhanced” rate

option. Choosing the correct Level of Care Type ensures appropriate

rate budgeting. (Refer to NC FAST’s Special Assistance – Level of

Care Evidence Job Aid in FAST Help for more information.)

B. Ongoing Cases

1. For ongoing cases, a new FL-2 must be obtained within 12 months from the date of the last one, before reauthorizing assistance. This could occur during the redetermination process or at any time during the certification period.

2. A new FL-2 must also be obtained when the beneficiary returns to the SA facility following time spent in a facility with higher level of care, or

3. A new FL-2 must also be obtained when the beneficiary enters a different SA facility following hospitalization.

4. For ongoing cases, the minimum requirements for an FL-2 to be

valid are the same as those listed in VII. A. 3. of this manual

section.

C. Additional Requirements for Special Care Unit Payments at the SA Enhanced Rate

There is a higher SA rate for SA beneficiaries in an adult care home SA-3100 VII.

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who reside in an SCU for Alzheimer’s or a related disorder. This

higher rate is known as the Enhanced rate. To qualify for the

Enhanced rate in a Special Care Unit, a/b’s must meet additional

requirements.

1. To approve SA in an adult care home for the Enhanced rate, the

FL-2 must have a diagnosis of Alzheimer’s disease or other forms

of dementia, characterized by dementing or memory impairing

conditions with irreversible memory dysfunction, and the a/b must

be placed in a licensed SA-approved SCU.

IMPORTANT NOTE: The term major neurocognitive disorder is

the updated terminology used in the DSM-5 to describe what was

previously known as dementia. Since these two terms are now

used interchangeably in both clinical and medical contexts, the

Special Assistance Program now also acknowledges major

neurocognitive disorder as interchangeable with dementia. As such, the use of major neurocognitive disorder shall be allowed and acknowledged to be the same as dementia when used on an FL-2. (Major neurocognitive disorder must NOT be confused with similarly named but unapproved diagnoses, such as “mild neurocognitive disorder”, “neurocognitive disorder”, or any variation of “neurocognitive impairment”. When in doubt about a diagnosis, contact the SA Listserv.)

For a list of licensed SCUs, see the Division of Health Service Regulation website for licensed SCU’s.

2. For an a/b in a SCU, a visit to the facility by a DSS employee must

be completed at both application, every redetermination, or when

a move from “basic” to SCU is reported, to verify placement in the

SCU unless the facility only has SCU beds. The onsite visit may be

completed and the residence in an SCU verified by any DSS staff.

3. Document the findings listed below.

4. If the facility has both ACH Basic beds and SCU beds, verify the

date the a/b entered the SCU by viewing the a/b’s facility record.

a. Verify the a/b is currently in the SCU by viewing the a/b’s room.

b. If the ACH has only SCU beds, telephone the facility to verify the date of entry.

c. If the a/b is not a resident of the county of eligibility, a request

to the DSS where the facility is located should be made to

complete the required visit for verification purposes. SA-3100 VII.

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D. Requirements for Enhanced Rate Payments for SAIH Beneficiaries With a Diagnosis of Alzheimer’s Disease or Dementia

The Enhanced rate is also available for SAIH beneficiaries in in-

home living arrangements who have a diagnosis of Alzheimer’s

disease or dementia. To approve SAIH for the Enhanced rate, the

SAIH a/b’s FL-2 must have a diagnosis of Alzheimer’s disease or

other form of dementia. (See SA-5200 II.)

SA-3100 VII.

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STATE/COUNTY SPECIAL ASSISTANCE MANUAL SA-3110 APPLICATION PROCESS North Carolina Division of Social Services Special Assistance Program Revised: June 1, 2026

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STATE/COUNTY SPECIAL ASSISTANCE MANUAL SA-3110 APPLICATION PROCESS

TABLE OF CONTENTS

I. Initial Contact A. Contact Via Mail B. Contact Via Phone C. Contact Via Mail-In Medicaid Application D. Applicant is Currently Residing in a State Institution E. Contact Via Agency Visit F. Timing of Applications Entered and Submitted in NC FAST G. Discouragement

II. Participation in the Application Process A. Who Can Sign the Application B. When an Individual Other Than the Applicant Makes an Application C. When an Authorized Representative Makes an Application D. When a Non-Authorized Representative Makes an Application

III. Accepting the Application A. Allow Applicant to Apply Without Delay B. Allow Applicant to Apply When There Is Anticipated Need C. Applicant May Apply For Program of Choice D. Informing Applicant of Timeframe In Which Eligibility Decision Must Be

Made E. When An Interview Cannot Be Completed In Same Day Application Is

Made

IV. Applications and County of Residence A. County of Legal Residence for SAIH Cases B. County of Legal Residence for Facility Cases C. Applicant’s County of Residence Cannot Be Established D. Applicant Presents for Application In County That Is Not the Legal SA

County of Residence (Courtesy Applications)

V. Explain to Applicant the Eligibility Requirements and the Application Process

VI. Explain to Applicant the Required Information Necessary to Process Application

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VII. Explain to the Applicant Their Rights and Responsibilities

VIII. Eligibility Determination Process A. Verify and Document Each Eligibility Factor B. Automated Inquiry and Match Procedures C. Review Online Data to Verify the SSI Status D. Complete a SA Facility Search in NC FAST E. Changes That Occur During Application Processing

IX. Time Standard A. Processing Time Standard B. When Applications May Pend Past 45th/60th Day C. Instances When an Application May Be Processed Beyond Time

Standard D. Disposing an Application

X. Establishing Disability for SA A. Currently Receiving SSI/SSDI B. Not Receiving SSI/SSDI, No Pending Application C. SSI/SDDI Application Pending D. SSA Makes No Disability Determination

XI. Re-opening A Denied SA Application Due to Appeal Reversal A. SA Appeal Reversal B. SSA Appeal Reversal

XII. Effective Date of Payment

XIII. Types of Disposition A. Approvals B. Open/Shut C. Denials D. Withdrawals

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I. INITIAL CONTACT

A. Contact Via Mail

If the applicant requests a Special Assistance (SA) application by mail, send the DSS-3000, Follow-up Letter Regarding Special Assistance Request within three business days of receiving the request. The letter

specifies that if the DSS does not hear from the applicant within 15 calendar days of the date of the letter, it will be considered that the applicant is no longer interested in applying for benefits.

B. Contact Via Phone

If the applicant requests a SA application by phone, explain that an application cannot be accepted by phone, fax, or email. Inform the applicant that a face-to-face interview is required. Request that the applicant come to the DSS for an interview. If the applicant states they cannot come into the agency for the face-to-face interview, offer a facility/home visit to complete the interview. Consider other arrangements to accommodate the applicant when reasonable circumstances prevent the individual from coming into the agency. Explain that an application must be signed to initiate the application process and a delay in signing an application may result in the loss or delay of benefits. Send the DSS-3000 Follow-up Letter Regarding Special Assistance Request. The form specifies, that if the DSS does not hear from the applicant within 15 calendar days of the date of the letter, the agency will assume that the applicant is no longer interested in applying for Special Assistance.

C. Contact Via Mail-in Medicaid Application

If a DHB-5200 or DHB-5201 Application for Health Coverage & Help Paying Costs is received and in talking to the individual or authorized representative, it is determined the individual intended to apply for SA, the DSS-8190 SSI/Non-SSI Application Workbook and other required application documents shall be completed as appropriate in an intake interview. Send a DHB-5097,Request for Information with a scheduled interview appointment for the individual and/or authorized representative to come into the Department of Social Services to complete the SA application. If the applicant does not show for the interview appointment send the DSS-3000 Follow-up Letter Regarding Special Assistance Request. The form specifies that if the agency does not hear from the applicant within 15 calendar days of the date of the letter, the agency will assume that the applicant is no longer interested in applying for SA. SA-3110 I.

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D. Applicant is Currently Residing in a State Institution

If the applicant is currently residing in a state institution, a properly

completed referral, DMA-5010, Referral for Inpatient Hospital and

Intermediate Care Facilities, may serve as an application document.

The date the referral is received by the agency is the date of

application.

E. Contact Via Agency Visit

When an individual comes into the agency and requests to make an

application for SA, explain the following:

1. An individual has a right to apply on that day.

2. An individual has the right to apply on her/his own behalf.

3. The official application for SA is the DSS-8190 SSI/Non-SSI

Application Workbook.

4. A face-to-face interview is required.

5. If the individual wants to apply on that day but cannot stay for the

interview, an interview appointment will be scheduled. The DSS

worker will:

a. Have the individual sign a DMA-5094, Notice of Your Right to

Apply for Benefits to protect the application date.

b. Explain that a completed Special Assistance application and a

face-to-face interview is required to complete the application

process.

c. Explain that the application cannot be processed unless an

application interview is completed.

d. Obtain the name of applicant, the name of the person requesting

the appointment, the address, and contact information.

e. Schedule a mutually agreeable appointment time for the interview.

When possible, make the appointment for the next business day.

f. Give or mail the DHB-5097 Request for Information, with the

scheduled date and time for the interview.

SA-3110 I.

24

6. If the individual decides not to apply that day, explain that they may

apply at any time. An inquiry (DMA-5095 Notice of Inquiry) must be

completed with areas of eligibility discussed, offered, and complete

documentation of why the applicant chose not to apply for assistance.

The following must be included with each inquiry and given to the

individual:

a. Have the DMA-5094, Notice of Your Right to Apply for

Benefits completed and signed and retain a copy. This will

protect the application date.

b. Have the DMA-5095 Notice of Inquiry completed and signed

and retain a copy.

F. All Special Assistance applications must be entered and

submitted into NC FAST within three business days from

the date the application is signed by the applicant.

G. Discouragement

An applicant or representative must not be discouraged from applying

for any assistance. Discouragement can occur with or without a signed

application and can be discovered in several ways, including a report by

the applicant or potential applicant through a second-party review, or by

the application monitor. Please refer to the ABD Medicaid Manual, MA-

2295 Discouragement.

II. PARTICIPATION IN THE APPLICATION PROCESS

A. Who Can Sign The Application?

1. An Adult (age 18 or older in the month of application) who is mentally

and physically capable, must sign the application.

2. If the applicant is under 18, mentally incompetent, or physically

unable to sign, an authorized representative can sign the application.

3. In certain situations, a non-authorized representative may sign an

application if either one of the following conditions are met:

a. To prevent the applicant from losing benefits because of a delay

in filing the application, when there is valid reason why the

applicant cannot sign the application.

SA-3110 I-II.

25

b. If the applicant resides in a state institution (mental hospital,

developmental center, or prison), information shall be obtained

from a responsible person or staff member of the institution.

NOTE: If the applicant is currently residing in a state institution,

a properly completed referral, DMA-5010, Referral for

Inpatient Hospital and Intermediate Care Facilities, may

serve as an application document, therefore no DSS-8190

is required. The date the referral is received by the agency is the date of application.

c. The circumstances to meet either condition must be clearly

documented in the case file.

B. When an individual other than the applicant makes an

application

Identify if the individual is an authorized representative or non-authorized representative.

1. A non-authorized representative is someone who applies on behalf

of an individual but does not have the legal authority to sign on

behalf of the individual. Non-authorized representatives are not

allowed access to that individual’s personal information used to

determine eligibility. Information regarding the application cannot be

shared with a non-authorized representative without written approval

from the applicant or an authorized representative.

2. An Authorized representative is any individual who is legally

authorized or designated in writing by the applicant to act on the

applicant’s behalf.

a. Types of Authorized Representatives listed below in hierarchy

order:

• Legal Guardian (includes DSS with custody or guardianship);

Guardianship is appointed by Clerk of Superior Court.

Guardianship is the legal relationship where an individual’s

authority to make decisions is replaced with the authority of

another (the guardian) when the Clerk of Superior Court

finds the individual no longer capable of making decisions

for themselves. In North Carolina, the laws concerning

guardianship are found in NC General Statute 35A

Incompetency and Guardianship - Proceedings To

Determine Incompetence. SA-3110 II.

26

• Power of Attorney (POA);

Appointed by the competent adult, the Power of Attorney

(POA) is an official document by which a competent

person (adult) appoints another competent person or

persons to assist in managing affairs of the person making

the appointment. The scope of the POA’s authority may be

broad or narrow as specified in the official document. Both

general and durable POA’s serve as attorneys-in-fact to

act in legal matters. The POA ends when the person who

made the POA appointment dies, or as a competent adult,

revokes the POA authority.

• Health care power of attorney;

A health care power of attorney designates an individual to

make health care decisions for an individual when the

individual no longer has the capacity to do so.

• Department of Social Services (placement responsibility only);

• Spouse (Not Separated);

• Parent (For children under 21);

• Authorized representative;

An individual designated in writing and signed by the

applicant to assist with eligibility issues and who can have

access to the information in the case file.

NOTE: The DMA-5202-Appendix C, Designation of

Authorized Representative is the authorized representative

form for Medicaid and accepted for Special Assistance. A

handwritten note stating such authority may also be

accepted but should be verbally verified with the applicant

at the start of the application process.

For any designation of authorized representative (or release of information) form used: the preferred method of signature is one that is legibly handwritten and made with a pen on a physical document to ensure validity and authenticity. However, individuals may also attest to entries on forms either by written signature or by electronic or digitized signature (in lieu of a signature in ink).

➢ For purposes of this policy, “attestation” means that, if requested, the author/signer of an entry can authenticate authorship, verify that the SA-3110 II.

27

contents of the entry are what the author intended, and can assume responsibility for the information.

➢ For the purposes of this policy, an “electronic signature” or a “digitized signature” is a digital signature that is unique to an individual by way of using a cryptographic, encrypted stamp of authentication applied to digital form, a digitized image of a signature obtained by using an electronic signature tablet or signature pad, or a scanned handwritten signature.

➢ For purposes of this policy, an “electronic signature” does not include a name typed as a signature on a form by the person(s) who completed the form unless a software application for the electronic record also applies a digital signature that serves as a unique identifier for the individual and provides a time/date stamp.

• Authorized representative as designated by SSA;

An individual who applied for and was approved by SSA to

be an authorized representative for the individual. Obtain

a copy of the SSA-L1697-U3 Notice to Representative of

Claimant Before the Social Security Administration.

NOTE: A representative payee and an authorized

representative are two separate appointments. Ensure that

you have verification of the authorized representative

and not the representative payee. OVS only identifies the

representative payee, not the authorized representative.

b. The IMC must enter the authorized representative on the

Person Page in NC FAST. The pathway is Person Page/Client

Contact/Contacts folder. Add new or select from a registered

individual. As a best practice this should be done prior to

dispositioning the application but can be done at any time

during the application process. Each type of Authorized

Representative must be identified by type in NC FAST.

C. When an Authorized Representative Makes an Application

1. Obtain verification of the authorized representative’s appointment.

2. The authorized representative may then complete the

application/interview. SA-3110 II.

28

3. Add the authorized representative to the Person page/Client

Contact/Contacts folder in NC FAST. Ensure the correct authorize

representative type is selected in NC FAST.

D. When A Non-Authorized Representative Makes an

Application

Explain to the non-authorized representative(s) that information

regarding an application and/or ongoing case cannot be released to the

non-authorized representative without written authorization by the

applicant or the applicant-authorized representative. Ask and document

the answers to the following questions:

1. Does the applicant have a legal power of attorney or guardian

appointed by the court system?

a. If the answer is yes:

(1) Document the POA or legal guardian’s name, address,

and phone number.

(2) Contact the POA to ensure they are aware that an

application is being requested and if they wish to complete

the application, they must answer all the questions on the

DSS-8190 SSI/Non-SSI Application Workbook.

(3) Have the non-authorized representative sign the DMA-

5094, Notice of Your Right to Apply for Benefits, to protect

the application date. Also give them a DSS-3000 Follow-

up Letter Regarding SA Assistance Request with a

scheduled appointment on it, and instruction that the

application must be completed and signed by the

POA, guardian, or an authorized representative.

Remind the non-authorized representative (and the POA

or guardian, if they can be reached) that the POA or

guardian may choose to appoint another individual as an

authorized representative by signing a DMA-5202C. The

IMC must mail the DMA-5202C to the POA or guardian.

However, until it is returned, no one other than the

applicant or POA/guardian can complete the application or

sign the DSS-8190 SSI/Non-SSI Application Workbook.

(4) Obtain a copy of the legal guardianship or POA

appointment and file the document in NC FAST.

(5) Include the guardian or POA on all case correspondence. SA-3110 II.

29

(6) As per the DSS-3000 Follow-Up Letter Regarding SA

Assistance Request, if the DSS does not hear from

someone who is authorized to act on the applicant’s behalf

within 15 calendar days of the date of the letter, the county

department of social services may assume the applicant is

no longer interested in applying for Special Assistance.

The date on the DMA-5094 is no longer protected as the

application date.

b. If the answer is no, proceed to the next question.

2. Why is the individual not applying on their own behalf? Is the

individual competent to answer the questions and able to sign the

application?

a. If the answer is yes, the applicant is competent, and the

applicant can sign (this includes making a mark):

(1) The applicant or an authorized representative must

complete the interview and sign the application.

(2) Have the non-authorized representative sign the DMA-

5094, Notice of Your Right to Apply for Benefits, to protect

the application date. Give the non-authorized representative a DSS-3000, Follow-up Letter Regarding SA Assistance Request with a scheduled appointment on it, and instruction that the application must also be completed and signed by the applicant or an authorized representative.

(3) If applicant is unable to come into the office, complete a

facility/home visit or make alternative arrangements.

Alternative arrangements may include, but are not limited

to, interviews conducted via a phone or skype.

Note: Questions regarding approved alternative

arrangements should be submitted to the SA listserv.

(4) As per the DSS-3000 Follow-Up Letter Regarding SA

Assistance Request, if the DSS does not hear from

someone who is authorized to act on the applicant’s behalf

within 15 calendar days of the date of the letter, the county

department of social services may assume the applicant is

no longer interested in applying for Special Assistance.

The date on the DMA-5094 is no longer protected as the

application date. SA-3110 II.

30

b. If the answer is yes that the applicant is competent, but the

applicant is unable to sign:

(1) The applicant or their authorized representative must

complete the interview. Document the reason why the

applicant cannot, at the current time, sign on the signature

line.

(2) Examples include, but are not limited to, both arms in

traction, burn victim whose hands are bandaged and

immobilized, and an individual who recently had eye surgery

and is unable to see to sign.

(3) Inform the non-authorized representative that the alleged

incapacity must be supported by a written statement

from a medical professional, such as a physician or nurse,

who is knowledgeable about the applicant’s condition. The

written statement must include:

• An explanation of the reasons the applicant is alleged to be physically incapacitated

• The approximate onset of the applicant’s incapacity

• A brief explanation of the nature of the incapacity, including medical conditions or diagnosis that caused it

• Expected duration of the applicant’s incapacity, AND

• The basis for the knowledge or opinion of the individual providing the explanation of incapacity

• The written statement and any related materials or documentation must not be older than 90 days prior to the application date.

(4) Have the non-authorized representative sign the DMA-

5094, Notice of Your Right to Apply for Benefits, to protect

the application date. Also give them a DSS-3000 Follow-

up Letter Regarding SA Assistance Request with a

scheduled appointment on it, and instruction that a written

statement is needed from a medical professional

regarding the physical incapacity that renders the

applicant unable to sign application documentation.

(5) Once the written statement is received, the application may

then be signed by the non-authorized representative to SA-3110 II.

31

prevent a loss of benefits for the applicant. If the applicant is

unable to come to the DSS, make immediate arrangements

to interview the incapacitated applicant via phone or facility

visit in order to get information to complete the DSS-8190.

(6) Documentation of the above questions and answer to

support the reason for a non-authorized representative

signing the application must be in the case file, along with

the written medical statement.

(7) As per the DSS-3000 Follow-Up Letter Regarding SA

Assistance Request, if the DSS does not hear from

someone who is authorized to act on the applicant’s behalf

within 15 calendar days of the date of the letter, the county

department of social services may assume the applicant is

no longer interested in applying for Special Assistance. The

date on the DMA-5094 is no longer protected as the

application date.

c. If the answer is no, indicating the applicant is not competent:

(1) Inform the non-authorized representative that the alleged

incompetence must be supported by a written statement

from either a physician, a nurse, a social worker, or a

psychologist. The written statement must include:

• An explanation of the reasons the applicant is alleged to be incompetent

• The approximate onset of the alleged incompetence

• The ending date of alleged incompetence, if the person has improved, AND

• The basis for the knowledge or opinion of the individual alleging the incompetence.

(2) Make a referral to the agency’s Adult Services or Adult

Protect Service (APS).

(3) Have the non-authorized representative sign the DMA-

5094, Notice of Your Right to Apply for Benefits, to protect

the application date. Also give them a DSS-3000 Follow

up Letter Regarding SA Assistance Request with a

scheduled appointment on it, and instruction that a written

statement is needed from a physician, nurse, social

worker, or psychologist regarding the applicant’s alleged

incompetence.

SA-3110 II.

32

(4) Once the written statement is received, the application may

then be signed by the non-authorized representative to

prevent a loss of benefits for the applicant.

(5) Documentation of the above questions and answer to

support the reason for a non-authorized representative

signing the application must be in the case file, along with

the written medical statement.

(6) If the DSS does not hear from someone authorized to act on the applicant’s behalf within 15 calendar days of the date of the DSS-3000, the county DSS may assume the applicant or non-authorized representative is no longer interested in applying for Special Assistance (and the DMA- 5094 no longer protects the application date).

Alternatively, and depending upon circumstances, the county DSS may contact the SA Listserv via a DSS-9000SA form to explain the situation and determine what can be done to prevent a loss of benefits and to avoid potentially endangering the applicant.

3. Is the non-authorized representative attempting to make a

courtesy application?

If a non-authorized representative wishes to make a courtesy

application in a county DSS which is not the applicant’s legal SA

county of residence:

a. Address all questions in this policy section (II. D.) with the non-

authorized representative. Follow the appropriate instructions

provided in this policy section based on the answers to the related

questions.

b. Have the non-authorized representative sign the DMA-5094,

Notice of Your Right to Apply for Benefits, to protect the application

date. Also give them a DSS-3000 Follow-up Letter Regarding SA

Assistance Request with a scheduled appointment at the DSS

potentially taking the courtesy application. Check off any/all

appropriate items on the first page of the letter.

c. As per the DSS-3000 Follow-Up Letter Regarding SA Assistance

Request, if the DSS that gave the DSS-3000 to the non-

authorized representative does not hear from someone acting on

the applicant’s behalf within 15 calendar days of the date of the

letter, the county department of social services may assume the SA-3110 II-III.

33

applicant is no longer interested in applying for Special Assistance.

The date on the DMA-5094 is no longer protected as the

application date.

d. If someone appropriate does act on the applicant’s behalf within 15

calendar days of the date of the DSS-3000 to complete the SA

interview (and provides any other documentation requested on the

first page of the DSS-3000), they may complete and sign the

application. The date on the DMA-5094 can then be used as the

application date. The DSS taking the courtesy application must

follow all guidelines regarding taking, submitting, and forwarding courtesy applications in SA-3110 IV.D.1-2. The county receiving the courtesy application still has the responsibilities given in IV.D.3.

4. NC Administrative Code related to authorized representatives can be

found in 10A NCAC 71P .0602.

III. ACCEPTING THE APPLICATION

A. Allow the applicant to apply without delay when the applicant requests a SA application.

Without delay is defined as allowing the application on the same day the

applicant, or a representative of the applicant, appears at the county

department of social services. Refer to SA-3110 IV. Applications and

County of Residence.

B. Allow the applicant to apply when there is an anticipated

need if the need will occur within the time standard for

completing the application.

C. Explain that an applicant may apply for the program of

their choice.

Discuss the advantages and disadvantages of both the SA and SAIH

programs.

D. Use the DMA-5094, Notice of Your Right to Apply for Benefits to inform the applicant verbally and in writing

that a decision must be made concerning eligibility within

45 days of the date of the application for SAA or 60 days

for SAD.

SA-3110 III.

34

The 45- or 60-days includes the time from date of application to the date

that the approval or denial notice is mailed. Exceptions to these time

frames include:

• The application may pend up to 6 months if the only remaining verification is citizenship and/or identity and the applicant is cooperating to the best of their ability or when it is the county’s responsibility to pursue verification on behalf of the applicant based on policy requirements.

• The application may pend up to 12 months when the applicant is not receiving, but may be eligible for, SSA Retirement, Survivors, or Disability Income (RSDI), or SSI, and is awaiting the SSA decision of eligibility.

E. When the interview cannot be completed on the same day,

a DSS staff member must:

1. Have the individual sign a DMA-5094, Notice of Your Right to

Apply for Benefits on the day the request for financial assistance is

received.

2. Explain the DSS-8190 SSI/Non-SSI Application Workbook is the

Special Assistance application and a face to face interview is required

to complete the application process. The signed DMA-5094, Notice of

Your Right to Apply for Benefits protects the application date.

3. Explain that the application cannot be processed unless an application

interview is completed.

4. Document the reason an application appointment was made and/or

requested.

5. Obtain the name of applicant, the name of the person requesting the

appointment, the address and contact information.

6. Schedule a mutually agreeable appointment for the interview. When

possible, make the appointment for the next business day.

7. Give or mail the DMA-5094, Notice of Your Right to Apply for

Benefits, with the scheduled date and time for the interview.

8. If the individual fails to keep the scheduled appointment, send a

second DHB-5097, Request for Information, scheduling a

second appointment. Schedule the appointment at least 13 days after SA-3110 III-IV.

35

the first appointment so there are 12 calendar days between

appointments. If the individual fails to keep the second appointment,

see SA-3110, Types of Disposition, for procedures to deny the

application.

IV. APPLICATIONS AND COUNTY OF RESIDENCE

The DSS staff begins the application process by determining the county of

residence. This is important because SA benefits are 50% State and 50% county

funds. When an individual or their authorized representative appears at a county

DSS outside of the individual’s county of residence, an application must be taken

following all guidelines in III. ‘Accepting Applications,’ above.

The applicant shall not be required to travel to another county or DSS to submit

an application. NC Administrative Code 10A 71P .0601 (1)-(3) requires that an

application for SA may be made in any county DSS without delay or on the same

day the applicant appears at the county department. Applications taken in a

county DSS outside of the individual’s county of residence are referred to as

‘courtesy applications.’

A. County of Legal Residence for SAIH Cases

The county of residence/responsibility for Special Assistance In-Home is

the county where the individual resides in private living with the following

exception:

• Identified Transitions to Community Living (TCL) individuals who are Special Assistance In-Home Approvals with Verified Supported Housing Slots are approved in the county of SA/Medicaid origin and then transferred to the county in which the applicant is currently residing in private living. These cases are the only SA cases that are allowed be transferred to another county and transferred as a SAIH case. See SAIH 5250.

B. County of Legal Residence for Facility Cases

The county of legal residence for SA facility cases is the county in which

the applicant last resided in a private living arrangement or intended to

establish a private living arrangement. Document the applicant’s prior (or

intended) living arrangement and county prior to entering

the SA facility, with the following exceptions:

• If the applicant states an intent to return home, thereby excluding the real property home site, the county of residence must be the county where the property is located.

SA-3110 IV.

36

• A child (under age 18) is always a resident of the State and County which is the legal residence of the parent(s) who have legal custody of the child. If the parent(s) with legal custody of the child move(s) out of a county and the child remains in a specialized community residential center, the new county of residence of the parent(s) will be financially responsible for the child the month following the month the parent(s) move to the new county. Transfer the case to the new county following transfer procedures in the relevant NC FAST Job Aids.

• If a child is in the custody of a county department of social services, that county is the child’s legal residence and thus financially responsible for the child until the child turns 18. Once a child turns 18, if a county DSS becomes the legal guardian of the adult, then the adult continues to be a resident of the county named as guardian.

• A disabled adult child (DAC) in a facility is a resident of the county and state in which the DAC’s parent(s) had residence immediately prior to the DAC reaching age 18.

C. Applicant’s County of Residence Cannot Be Established:

1. The county of residence is the county in which the applicant is

currently applying for SA.

2. If the applicant resides in a facility at the time of application, the county

of residence is the county in which the SA facility is located.

D. Applicant Presents For An Application in a County DSS

Which is Not The Applicant’s Legal SA County of

Residence:

When an applicant presents for an application in a county DSS which is

not the applicant’s legal SA county of residence the DSS will complete a

courtesy application.

1. Obtain the following: • A completed, signed and legible, DSS-8190 SSI/Non-SSI Application Workbook with complete name, address, and contact number for applicant and/or authorized representative;

• A DMA-5094, Notice of Your Right to Apply for Benefits;

• A signed DMA-5052SA, State/County Special Assistance Beneficiary Estate Subject to Medicaid Recovery Notice;

SA-3110 IV.

37

• A DSS-3431, Request for Financial Information, if appropriate;

• Register of Deeds/property check (including parents’ names, spouse’s name(s), spouse’s parents’ names), and any other leads, if appropriate

• Verify all other available online verifications (SOLQI, OVS, On- Line Data, AVS) as appropriate;

• A DHB-5097, Request for Information (which must include the request for FL-2, if not provided)

NOTE 1: If a disability determination is necessary or being

requested, refer to Medicaid policy.

NOTE 2: If an applicant applies in more than one North Carolina

county, the county of legal residence will process the application

protecting the first date (earliest date) of application.

NOTE 3: If there is a dispute between counties concerning the

above procedures, contact SA Program Representatives by sending a DSS-9000SA form to the SA listserv at specialassistance@dhhs.nc.gov.

2. The DSS taking the courtesy application has the following

responsibilities:

a. Submit the application in NC Fast. Follow the relevant NC FAST

Job Aid to transfer the application to the county of residence

within two (2) business days.

b. Contact the county of residence to ensure that they are aware of

the application. The application should appear as a task in the

county of residence’s work queue for processing.

c. Send all items concerning the complete application

electronically or by US Mail to the DSS in the applicant’s

county of residence within 24 hours or one business day. If

the application date falls on the day before a weekend or holiday,

forward all the information the following business day.

d. Notify the contact person at the applicant’s county of residence

that the application has been mailed.

e. Maintain a copy of all the application information, in case the

information is lost or destroyed in the mailing process.

SA-3110 IV.

38

f. Any additional information received must be delivered to the

county of residence within two business days of receipt.

g. The date of application is the date the applicant and/or authorized

representative requested financial assistance and signed the

DMA-5094 Notice of Your Right to Apply for Benefits.

h. A suggested form to notify the beneficiary of the change in the

county DSS which will be maintaining the case is the DSS-3001

Notice of County of Residence Reassignment/Transfer form.

NOTE: If more than two business days have passed after taking

an application and the DSS learns that the applicant is a resident

of another county, the DSS with the open application must

process the application. Once the application is approved, clearly

document the beneficiary’s SA case file with verification of the

correct county of residence. Initiate reassignment of the now

ongoing case to the correct county of residence. A suggested

form to notify the beneficiary of the change in the county DSS

which will be maintaining the case is the DSS-3001 Notice of

County of Residence Reassignment/Transfer form.

3. The county receiving the courtesy application has the following

responsibilities:

a. Document the initial contact from the county taking the courtesy

application. b. Acknowledge receipt of the application in writing. c. Process the application following SA procedures.

d. Maintain the case.

NOTE: Courtesy applications accepted from another county

become the responsibility of the receiving county. It is

recommended that, after receiving a courtesy application, the

receiving county review the case for accuracy and contact the

processing county to correct any errors.

4. For situations in which a non-authorized representative wishes to

make a courtesy application, refer to policy in II.D.3.

SA-3110 IV-V.

39

V. EXPLAIN TO EACH APPLICANT THE ELIGIBILITY

REQUIREMENTS AND THE APPLICATION PROCESS

A. The SA program is a state supplement to the federal SSI

program. If the applicant’s income is less than the federal

benefit rate (FBR) for SSI, the individual is required to

apply for SSI. The FBR is the basic standard used in

computing the amount of SSI benefits for individuals and

couples. The FBR may be increased annually to reflect

increases in the cost of living.

B. Special Assistance provides a cash payment.

C. Special Assistance and Special Assistance In-Home

automatically qualifies the applicant for Medicaid for non-

SSI Recipients.

This does not apply to the SA for Certain Disabled Program. D. Explain Retroactive Medicaid and discuss if there is a need

for retroactive Medicaid benefits.

If the applicant does not request or is clearly not eligible for Medicaid that

is retroactive to the SA application month, document in the SA case file

that retroactive Medicaid was offered and the reason that no retroactive

application was taken.

E. When the applicant accepts Medicaid, they assign their

right to third party insurance benefits to the state.

Inform the applicant that it is a misdemeanor to fail to disclose the

identity of any person or organization against which they have the right

to recovery of medical expenses paid by Medicaid.

F. Each applicant must apply for all monetary benefits to

which the applicant may be entitled to, including receiving

the maximum benefit for which the applicant is eligible.

The individual cannot waive or renounce benefits that they

may be eligible to receive, this includes but is not limited to

SSI.

SA-3110 V.

40

G. Special Assistance benefits cannot begin prior to the

month in which an application is signed. There are no

retroactive benefits for SA prior to the month of

application.

H. If an applicant is required to apply for SSA benefits, SA

benefits cannot begin until SSA has made a determination

of eligibility, including disability for a person under age

65. NOTE: Because SA is a state supplement to the federal SSI program, to be eligible for SA an individual must apply and be eligible for SSI or be found ineligible for SSI solely due to being over income for SSI. For additional information on SSI and the SA application, see SA-3110, VIII Establishing Disability for SAD.

I. The SA application may pend up to 12 months, if awaiting a

decision from SSA.

J. If the applicant applied for SSA and was denied, and their

appeal time frame has not lapsed, they may appeal the

SSI/RSDI denial. It is in the best interest of the individual to appeal the SSI/RSDI denial. For example, if they appeal the SSI/RSDI denial and win the appeal two years later, the SSI/RSDI benefits will be retroactive to the original SSI/RSDI application date. If they are denied and do not appeal, they would have to reapply for SSA/SSI and even if found eligible back to the original application date, the SSI/RSDI benefits will only go back to the most current application date.

NOTE: SA does not pend the SA application while waiting for the

SSI/RSDI appeal process. The SA application must be denied. Explain to

applicant that if the SSA appeal results in a reversal to approve SSI/RSDI

retroactive to the date of SA denial, the SA application can be re-opened

and SA benefits approved if all other eligibility conditions are met.

K. If SSA denies the SSDI/SSI application based on non-

disability or not meeting criteria for legal blindness, or

denies based on eligibility criteria other than income (such as resources, transfers, fleeing felon, etc.), the SA application will also be denied. This is because in SA-3110 V.

41

order to qualify for SA an individual must be eligible for SSI or ineligible solely due to being over income for SSI.

L. If the DSS denies an SA application based on an SSA

denial, advise the applicant that he may appeal the SSA

decision. If SSA reverses their denial, the SA application

may be reopened. See instructions in SA-3110, VII.

Application Process for reopening applications due to SSA

appeal reversals.

M. Explain what a change in circumstance is, and when to

report it.

N. Explain the meaning of fraud and provide the Public

Assistance Fraud Pamphlet to the applicant or Authorized

Representative.

O. Explain the annual recertification process. Refer to SA-

3320, Redetermination of Eligibility.

P. Discuss other available services and make appropriate

referrals.

Q. Discuss how the applicant will receive the SA payment

unless they, or their authorized representative, choose to

have a substitute payee. Refer to SA-3200 Administration

of Benefits.

R. The applicant must choose direct deposit or EBT cash card

as their payment method and fully explain each option. A

facility cannot require a SA payment to be deposited into

a collective account.

VI. EXPLAIN TO THE APPLICANT THE REQUIRED

INFORMATION NECESSARY TO PROCESS THE

APPLICATION

A. Social Security numbers will be used to match information

with other agencies such as the Internal Revenue Service SA-3110 V-VI.

42

(IRS), Employment Security Commission (ESC) and Social

Security Administration (SSA).

Matches will be done unless withdrawal of the application is requested.

A DHB-5001N, Notice on the Use of Social Security Numbers, must be given to all applicants (in person, or via mail when necessary). The DHB- 5001N is not required to be signed or returned. The form is for notification purposes only. Documentation should be added to the case record indicating when the form was given (or sent).

B. Inform the applicant that when other verification cannot be

provided, it is the county's responsibility to use collateral

sources to substantiate or verify all necessary information

to establish eligibility.

Collateral sources of information include knowledgeable individuals

(landlords, business organizations, public records, and documentary

evidence. Failure to provide collateral contacts can result in the

application being denied for failing to cooperate in establishing eligibility.

C. The IMC may visit the applicant’s residence or SA facility, if

necessary, to verify eligibility requirements.

The application will not be denied if the applicant is unavailable during an

unannounced visit.

D. Discuss Carolina ACCESS, the managed health care

program for Medicaid and North Carolina Health Choice

(NCHC) recipients.

Refer to MA-2425, Community Care of North Carolina/Carolina Access

(CCNC/CA) for instructions.

E. SSI payments and any other income the applicant receives

will be considered by calculating the SA payments.

F. SA eligibility is based on need as indicated by the

recommended level of care.

If the FL-2 form presented to the IMC is invalid due to missing information and/or needs correction, explain that the original physician/physician assistant/nurse practitioner who signed the FL-2 can correct the form by completing or correcting the blank boxes and by adding their initial and date next to each correction. No one other than the medical originator SA-3110 VI.

43

who initially completed the FL-2 can alter the information on the FL-2. Refer to SA-3100 Eligibility Requirements for instructions regarding the Adult Care Home FL-2 requirement and what constitutes a valid FL-2.

G. The county must verify their residence.

H. If requested verification cannot be obtained by the second

due date, the applicant should notify the IMC to request an

extension of an additional 12 days.

I. The IMC must inform the SSA via DHB-5049 Referral to

Local Social Security Office of the change in living

arrangements.

Remind the applicant/authorized representative that it is their responsibility

to notify SSA within 10 days of any change in situation.

J. When the applicant accepts Medicaid, they assign their

right to third-party insurance benefits to the state.

Inform the applicant that it is a misdemeanor to fail to disclose the identity

of any person or organization against which the applicant has the right to

recovery of medical expenses paid by Medicaid.

K. Explain that the meaning of fraud is when an individual

willfully and knowingly (with the intent to deceive) makes

false statements or misrepresentations, fails to disclose

information, or fails to report a change in situation.

In such situations, the applicant/beneficiary may have to repay assistance

received in error and that they may also be tried by the courts for fraud.

VII. EXPLAIN TO THE APPLICANT THEIR RIGHTS AND

RESPONSIBILITIES

A. Explain, in detail, the applicant’s rights:

1. The right to apply on their own behalf at any time.

2. The right to receive assistance if found eligible.

3. The right to have any information given to the agency kept in

confidence, in accordance with the federal and state laws and policies SA-3110 VI-VII.

44

4. The right to be protected against discrimination on the grounds of

race, creed, or national origin by Title VI of the Civil Rights Act of

1964. Appeals based on discrimination should be made to the DSS

director.

5. The right to be the payee for the SA payment unless the applicant or

their authorized representative designates a substitute for the

payment.

6. The right to choose how they receive their SA payment, via EBT card

or Direct Deposit into a personal account or a facilities collective

account.

7. If approved, the right to receive their SA payment until the payment is

terminated by appropriate action.

8. The right to appeal, if:

a. Assistance is denied, changed, or terminated.

b. Applicants believe the payment is incorrect based on the county's

interpretation of state regulations.

c. A request for a review of his or her eligibility decision including

payment amount was delayed beyond 30 days or the request for

review was denied.

9. The right to reapply at any time, if found ineligible.

10. The right to withdraw from the SA program at any time.

B. Explain in detail the applicant’s responsibilities:

1. To apply for all monetary benefits to which the applicant may be

entitled, including receiving the maximum benefit for which the

applicant is eligible. The individual cannot waive or renounce benefits

that they may be eligible to receive. This includes but is not limited to

SSI.

2. To apply for SSI if their income is below the SSI Federal Benefit Rate

(FBR).

a. Explain to the applicant who receives SSI but whose SSI payment

amount is less than the FBR, that they will need to work with SSA

to establish income up to the FBR. SA-3110 VII.

45

b. Explain that SA payments cannot be issued in an amount to make

up for SSI income deficit when the total gross income is less than

the FBR and is reduced for any reason other than:

(1) Social Security Administration (SSA) overpayment

recoupment (when SSI or RSDI income is garnished for any

reason other than to recoup an SSA overpayment, the total

monthly income, including the amount that is being

garnished is entered as evidence and is countable.

(2) SSI couple deeming.

(3) SSI denials due to life insurance excesses for those who had specific life insurance face/cash value policies prior to

December 1, 2009; and

(4) SSI determinations related to private living reductions for

SAIH cases such as one-third reduced and in-kind support

and maintenance.

3. To apply for RSDI/SSI within the SA application processing time

standard, if required. 4. To reapply for SSI/RSDI by the SA application processing deadline if the under 65 applicant was previously denied SSI/RSDI for not being disabled, and is not in appeal status and the appeal time frame has lapsed.

5. To reapply for SSI/RSDI by the SA application processing deadline if the applicant was previously denied SSI/RSDI, the applicant’s income is below the FBR limit, and the applicant is not in appeal status and the appeal time frame has lapsed.

6. To provide the necessary information/verification required to

determine eligibility, a DHB-5097, Request for Information

will be given/sent identifying all required information. If

assistance is needed in obtaining verifications, the applicant

must notify the IMC and/or sign a release of information.

NOTE: Only the applicant, the applicant’s legal guardian or the

applicant’s duly appointed POA can legally sign the consent form. If a

legal guardian or an appointed POA is signing for the applicant, they

must sign the applicant’s name followed by their own name. Refer to

DSS-6969, Consent for Release of Information for a suggested form. SA-3110 VII-VIII.

46

7. To report within 5 calendar days any change in situation that may

affect SA eligibility. Explain the meaning of fraud. Notify the applicant

they may be suspected of fraud if the applicant/beneficiary fails to

report a change in situation. Explain that in such situations, the

applicant/beneficiary may have to repay assistance received in error

and that they may also be tried by the courts for fraud.

8. To provide information about any person or organization from which

Medicaid has a right to recovery of medical expenses that were paid

by Medicaid.

9. To sign a DMA-5052SA, State/County Special Assistance Beneficiary

Estate Subject to Medicaid Recovery Notice because Medicaid is

automatic for SA facility beneficiaries, inform applicants of the

potential for estate recovery for the cost of PCS paid by Medicaid for

beneficiaries age 55 and older. Regardless of age at application,

have the applicant or their representatives sign the DMA-5052SA,

State/County Special Assistance Beneficiary Estate Subject to

Medicaid Recovery Notice. Provide a signed copy to the applicant

and/or representative and retain a copy of the case file. 10. To report within five business days to the county DSS the receipt of a

payment, which the SA beneficiary knows to be erroneous, such as

two payments for the same month, or a payment in the wrong

amount. Failing to report such payments may result in the SA

beneficiary being required to repay any overpayments.

VIII. ELIGIBILITY DETERMINATION PROCESS The following steps shall be followed in determining eligibility. Review each

eligibility factor following the policy in the appropriate manual sections.

Document all factors of eligibility on the DSS-8190 SSI/Non-SSI Application

Workbook. Date-stamp all information with date of receipt in DSS including

electronic date received stamps. Document in the case record all applicant,

collateral, and telephone contacts, including the full name and title of who

provided the information and what they verified.

NOTE: SSI Recipients automatically meet the categorical, financial and

resource requirements.

A. Verify and document each eligibility factor SA-3110 VIII.

47

1. Identity for non-SSI or non-Medicare applicant, if not already

verified in NC FAST. (See SA-3240.)

2. Age or Disability Requirement

a. Age (See SA-3100 III.)

b. Disability or blindness if under age 65:

View SDX Disability Onset, which indicates if there is a date of

disability onset as alleged by the claimant during the period in

which the case is awaiting a medical determination, or if the case

has been medically denied.

c. After a final disability or blindness determination has been made,

the date of onset will be either the date of disability onset

established for Title II (RSDI) purposes in a concurrent Title II/Title

XVI allowance or the date of onset established for Title XVI only

medical allowances.

3. Residency in a licensed adult care facility or in-home living

arrangement, if applying for SAIH. Document the date of admission

on the DSS-8190 SSI/Non-SSI Application Workbook.

4. Receives SSI or is ineligible for SSI solely due to having excess income for SSI.

5. Level of Care required for applicants residing in an adult care facility.

(SA-3100 VII.)

6. State Residency (SA-3100 IV.)

7. U.S. Citizenship for non-SSI or non-Medicare applicant’s if not already

verified in NC FAST and documented in the Permanent Verifications

folder. (Refer to SA-3240, Citizenship and Identity.)

8. Not receiving Medicaid in the same month the applicant becomes

eligible for SA if receiving under Certain\Disabled Program.

9. Transfer of resources (Refer to SA-3205.)

10. Resources (Refer to SA-3200.)

a. For SSI recipients, view SDX resources, showing the resource

information that the applicant has provided to Social Security.

Recipients of SSI automatically meet the resource requirements

of SA; however, SSI resource information could provide eligibility

leads that need further exploration. For example, if the SDX SA-3110 VIII.

48

reflects ownership of a home which is excluded for SSI,

document the SA case file with the physical location of the home

for purposes of state/county residency. SDX also provides

information on transfer of assets.

b. For non-SSI recipients, review all leads thoroughly for resources.

(See SA-3200.)

11. Income (See SA-3210.)

12. Budgeting (See SA-3220.)

B. Automated Inquiry and Match Procedures: (SA-3400)

1. Complete an OVS/OLV and AVS Online Data request.

2. Ensure correct base period is used to run matches. (See SA-3210 II.)

C. Review the Online Data to verify the SSI status of the SA

applicant to correctly determine SA eligibility.

1. Competency Code indicates the representative payee's status as to

legal guardianship and/or competency of the recipient.

2. Review to see if there is a substitute payee indicated for the SSI

check.

3. Review the SSI Eligible Date, the date the recipient was first

determined eligible or most recently re-determined eligible after a

period of ineligibility. This is the effective date of the first SSI payment.

SSA also calls this the Application Effective Date.

4. Review the Federal Eligibility Code which identifies eligibility for SSI

payment in the current month.

5. Review the Payment Status, which consists of two data elements: • The first position reflects the status of the SSI payment. • The second and third positions reflect the reason for the status.

6. Review the current SSI benefit amount.

NOTE: SA applicants with income/benefit evidence entered into NC

FAST less than the FBR, excluding individuals that qualify for a

‘Reason not receiving SSI FBR’, will fail the income test in NC FAST.

SA-3110 VIII.

49

7. If the applicant’s income is below the federal benefit rate (FBR),

determine if one of the following valid reasons to be receiving less

than the FBR applies. If so, the reason must be entered in NC FAST in the Benefit/Unearned Income evidence field. See details of the reasons and when to use them in SA-3210 V.B.

a. One-Third Reduced SSI (Unearned Income Information). If the

Online Data reflects unearned income code “J” for the SA

applicant/beneficiary this indicates that the applicant’s SSI

payment is based on the applicant residing in the home of another

person.

b. SSI In Kind Support/Maintenance Ending

If the online Data reflects SSI Recipients with SSI income based

on SDX Code “H”, In kind Support.

c. Life Insurance (with) Cash Accruing Face Value Greater Than

$1500. If the online data reflects LI indicator displays as “Yes” on

Liquid Resource evidence/Liquid Resource Details/SA Special

Review Code. See SA-3210 V. B.

d. SSA Recoupment of Overpayment

If the online data reflects a dollar amount in the Monthly

Overpayment Recovery Amt field this is the monthly overpayment

amount being reduced from the SSI payment.

e. SSI Couple Deeming

Required for cases with gross monthly income less than the FBR.

Case Special Review Code, “N” ‘SSI Couple Deeming’.

NOTE: Refer to SA-3210 V. B. for Case Special review codes.

8. The Online Data Denial Code-Date provides the reason and date a

claimant was previously denied for SSI.

NOTE: Remember, to be eligible for SA the individual must be SSI

eligible or be ineligible solely due to being over income for SSI.

D. Complete a SA facility Search in NC FAST

1. Verify in NC FAST that the facility is SA eligible by conducting a facility

search. There are many facilities with the same or similar names,

ensure the facility name address and license number display correctly

in NC FAST. It is a best practice to obtain the facility license number

and search via the license number. SA-3110 VIII-IX.

50

2. For information on facilities that are designated as a SA Facility, see

SA-3100.

NOTE: If a facility is not found in the facility search or facility

information is inaccurate such address, license number, or name

contact the SA listserv.

E. For changes that occur during the application processing

time, refer to SA-3310 Change in Circumstance

IX. TIME STANDARD

The time standard covers the time from the date the application or DMA-5094 /

5094S, Notice of Your Right to Apply for Benefits is signed to the date of

disposition. Do not deny an application for failure to provide verifications prior to

the 45/60th day.

A. Processing Time Standard

1. Process SAA applications within 45 days from the date the DMA-5094

Notice of Your Right to Apply for Benefits is signed.

2. Process SAD applications within 60 days from the date the DMA-5094

Notice of Your Right to Apply for Benefits is signed.

B. Applications may pend past the 45/60th days when:

1. The applicant applied for SSA, but is waiting for SSA/SSI

determination. The SA application may pend up to 12 months while

awaiting a determination of eligibility for benefits and/or a disability or

blindness determination and/or other information needed from SSA.

Refer to SA-3110 X. Establishing Disability for SA.

NOTE: Do not pend an application if you are waiting for the SSI

payment to increase to FBR. Refer to SA-3210 V. D.

2. If the citizenship or Identity verification is the only verification still

pending and the applicant is cooperating to the best of their ability or

when it is the county responsibility to pursue verification on behalf of

the applicant based on policy requirements. The application may pend

up to 6 months.

NOTE: Assistance in obtaining Citizenship and Identity documentation

must be provided upon the applicant’s request or if the applicant has

special needs, such as a mental or physical incapacity. Refer to SA-

3240, Citizenship and Identity. SA-3110 IX.

51

3. The applicant reports they need additional time to provide verification.

Send a third DHB-5097, Request for Information allowing an

additional 12 days to provide the verification and those 12

days extend past the 45/60th day.

C. Instances When an Application May Be Processed Beyond

the Time Standard

There are certain situations that would require the application to be

processed beyond the time Standard. These instances must be

documented in the case record. This documentation and the reason will

determine if the case is in error or not. If the application pends beyond the

processing time standard, dispose of the application within 5 business

days after the last piece of information is received or the last due date if

verification is not received.

1. The requirement for two DHB-5097, Request for Information

has not been met and/or they were not sent at least 12

calendar days apart for any required verification, including information

discovered after a DHB-5097, Request for Information

is sent but not previously requested.

2. If it is discovered that the applicant is over resources, and two

DHB-5097, Request for Information, were not sent at least 12

calendar days apart to explain and request the spend down of

resources.

D. Disposing an Application

• When disposing of a pending application, determine eligibility on a monthly basis for all months from date of application onward. Clearly document the application booklet for each month of non-eligibility listing the reason/s for non-eligibility. Notify the applicant accordingly. When all factors of eligibility are met, clearly document the basis for eligibility, including first-moment resource balance when applicable.

• If the applicant provides verification that resources were reduced prior to the 12-day period of the second DHB-5097, Request for Information, determine eligibility based on the new resource amount.

• Eligibility begins the month after the month in which resources were reduced to allowable limits. The exception to this rule is if the burial exclusion is sufficient to reduce resources to the allowable limit.

SA-3110 IX-X.

52

X. ESTABLISHING DISABILITY FOR SA

To be eligible for SAD, an individual must be age 64 or under, and must be

determined disabled by Social Security meet criteria for legal blindness.

A. Currently Receiving SSI/SSDI

An applicant who is receiving SSI/SSDI based on disability meets the

disability requirement.

B. Not Receiving SSI/SSDI, No Pending Application

1. If the SA applicant is not receiving SSI/SSDI based on disability or

legal blindness has not been established, and does not have a

disability application pending, advise the applicant that they

must apply for Social Security benefits within 60 days of the date of

the SA application.

2. Discuss the applicant’s current and retroactive medical needs and

advise the applicant that they may make a separate application for

Medicaid. Refer to instructions in MA-2525, Disability for establishing

disability for Medicaid. A Disability Determination Services (DDS)

decision of disability for Medicaid does not apply to SA, except for

situations described in D.

3. If the applicant applies for SSI/SSDI within the 60-day processing time

standard, hold the SA application pending up to 12 months awaiting

the SSA decision.

4. If SSA denies the application due to not meeting criteria for disability

or legal blindness, deny the SA application. Advise the applicant that if

he appeals the SSA decision and the denial is overturned, the SA

application may be reopened.

C. SSI/SSDI Application Pending

1. If the applicant has an application for SSI/SSDI pending with SSA,

hold the SA application pending for up to 12 months awaiting the

Social Security decision. Check the SDX monthly to determine if a

decision has been made and document this.

2. If the SSA disability application is denied due to not meeting criteria

for disability or legal blindness, deny the SA application. Advise the

applicant that the SA application may be reopened if he appeals the

SSA decision and the denial is overturned in appeal. SA-3110 X.

53

D. SSA Makes No Disability Determination

1. In some cases, SSA may approve or deny benefits without

determining disability. For example, the applicant may be financially

ineligible for both SSDI and SSI and the application is denied without a

disability determination, or an applicant may be approved for a benefit

that does not require a disability determination such as early

retirement.

2. When SSA approves, or denies benefits, determine the reason for the

decision and whether a disability decision was rendered. Refer to the

SDX, SOLQ, award or denial letter or contact with SSA.

3. In situations, where SSA will not make a disability determination,

disability must be established by Disability Determination Services.

Follow instructions in MA-2525, Disability to submit a request for a

disability determination for an SAD applicant.

4. The only time DDS makes a disability determination for SAD is when

SSA will not make a disability determination.

5. In situations where SSA will not make a legal blindness determination,

blindness must be established by the Division of Services for the Blind.

Proof of an individual’s visual acuity will be based on a completed eye

examination report which reflects their current visual condition.

a. The eye examination report must be dated and signed by a

medical or eye care professional. Acceptable report forms are:

(1) DSB-2202: Report of Eye Examination, which is completed,

dated, and signed by a medical or eye care professional; or

(2) A written statement on official letterhead signed and dated

by a medical or eye care professional which states, at

minimum, the individual’s visual acuity in both eyes with best

correction, date of examination, and primary diagnosis.

b. Mail to:

Division of Services for the Blind

2601 Mail Service Center

Raleigh, NC, 27699-2601

SA-3110 X-XI.

54

XI. REOPENING A DENIED SA APPLICATION DUE TO

APPEAL REVERSAL

A. SA Appeal Reversal

When a SA application was denied but is subsequently approved as the

result of a state appeal, administratively reopen the original application

within 5 business days of the date the Notice of Decision is final. Process

the reversed decision.

B. SSA Appeal Reversal

If the SA application is denied based on a decision by SSA but the SSA

denial is reversed on appeal, the reversal of the SSA decision is

considered a reversal of the SA decision. The applicant is not required to

make a separate SA appeal. This applies to determinations of eligibility

based on disability or as well as other eligibility factors such as resources

or transfers.

1. Administratively reopen the SA application back to the original date of

app if:

a. The applicant or the representative notifies the county DSS within

60 days of the date of the reversal decision and requests SA, and

b. The onset date for disability or blindness (or the beginning date of

eligibility) is the same as or prior to the date of the SA denial, and

c. There is a period of cost of care that SA can cover.

2. The IMC should check to determine if the appeal process has been

completed, through the SDX or by contact with SSA or the applicant.

If it is learned of the appeal decision through some source other than

the applicant, contact the applicant to determine if they wish to

reopen the SA application based on these criteria.

3. Approve assistance based on the original date of application if all other

eligibility factors are met. Payment can begin no earlier than the month

of SSI approval. Refer to SA-3110 XII. Effective Date of Payment.

4. Request a Medicaid Override, if the applicant is authorized for

more than 12 months prior to disposition, send a letter to the Payment

Benefits Section Also, if Medicaid is authorized more than 12 months

prior to disposition, request an override of the 12 months Medicaid

claims processing time limit.

SA-3110 XI-XII.

55

XII. EFFECTIVE DATE OF PAYMENT

A. Do not authorize the SA payment prior to the date a current

valid FL-2 is signed by a physician, a physician assistant,

or a nurse practitioner for adult care home cases.

Calculate a partial payment beginning with the date the valid FL-2 is

signed, and all other factors of eligibility are met, if that date falls after the

first day of the month. In general, the effective date of payment is the day

when the FL-2 is signed.

B. If an applicant is in a SA facility for an entire month and

eligibility requirements are met after the first day of the

month, the applicant is not eligible for a full month

payment until the following month.

An exception is for an applicant reaching age 65. In these situations, if the

applicant meets all other eligibility requirements, they are eligible the

month they attain age 65.

C. Do not authorize SA payment for months prior to the

month of application.

D. For SA applicants who are also applicants for SSI,

authorize SA payments the first month the applicant

becomes eligible for SSI (even if no SSI payment was issued/received) if applicant resides in a licensed SA

facility and applied for SA that month, and met all other

factors of eligibility.

1. The first month the SSI applicant meets all factors of SSI eligibility is

identified by SDX/SSI Payment Status Code E02. Code E02 indicates

the SSI application month for which no SSI payment is issued. The

first SSI payment is issued the month following the first E02 month of

SSI eligibility.

2. Because the SSI payment will not be issued to the SSI applicant for

the E02 month, the SA payment will be calculated for the SSI E02

month at zero SSI payment. The SA payment will need to be

recalculated for subsequent months for which the SSI applicant is

awarded/issued SSI payments ongoing. These months are coded on

the SDX as C01 months.

SA-3110 XII-XIII.

56

NOTE: If SSI ongoing payments are not awarded at SSI FBR for the