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3. The DSS will acknowledge receipt of the direct contact and inform the
LME/MCO transition coordinator to submit the DSS-0034 Appendix E
Supplement 2.
4. The DSS will determine and inform the LME/MCO if the case is an
active SAACH case or if a face-to-face full interview is required for a
non-active SA-ACH case.
5. Inform the LME/MCO transition coordinator that the individual may
have a contractual agreement to provide a 14-day written notice to the
facility when moving out of the facility. When the required notice is
given, the individual owes the facility a per-diem amount through the
notice period. This amount is the number of days in the month divided
by the basic Special Assistance Rate.
C. Active SA ACH Case
1. Once the written request via the DSS-0034 Appendix E. Supplement 2
is received for an active SA case in an adult care home, the DSS IMC
in the county of Medicaid/SA eligibility will gather information relevant
to establishing the planned living arrangement, changes in finances
or available resources/assets, county of private living residence, and
other pertinent eligibility information.
2. Document actions taken on the case, determine the amount of the
maximum SA payment and determine if the individual needs an
updated FL-2.
a. If the FL-2 is current (will not expire within the next 30 days) and
valid, a new FL-2 is not required. Ensure that the date of the FL-2
is recorded correctly at the Certification Start Date of the Level of
Care Evidence in the NC FAST system.
b. If an FL-2 is needed, inform the LME/MCO transition coordinator
immediately that a new FL-2 is needed and what a valid FL-2 is for
SAIH. Information on a valid FL-2 is found in SA-5200 and SA-
3100. The FL-2 must indicate the individual requires a need for
licensed residential level of care (Block #11) and be signed by a
licensed physician, physician assistant, or nurse practitioner.
4. Send a DHB-5097 with the DSS-0033 Appendix E, Supplement 1
requesting all information needed to determine eligibility.
SA-5250 VIII.