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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD If parent of applicant does not return completed Form NMO-7011 Income Review/Premium Payment Agreement, the Division Institutional staff will email DHCFP at dhcfpkatiebeckett@dhcfp.nv.gov, advising that no signed Form NMO-7011 Income Review/Premium Payment Agreement was received. If no signed Form NMO-7011 Income Review/Premium Payment Agreement is received back from a parent of applicant DHCFP will assess the maximum monthly premium of $250.00 Note: DO NOT terminate a case for not receiving a signed Form NMO-7011 Income Review/Premium Payment Agreement back from the applicant’s parent. Change in Income and/or Household Size Reported: Verify reported change in income and/or household size. The Division will complete Form NMO-7013 Income Review/Payment Agreement Amendment. The Division will use Form NMO-7011B Payment Agreement Guide, (Katie Beckett Premium Matrix), to determine family’s monthly premium amount. The Division will request a signature by parent of applicant on Form NMO-7013 Income Review/Payment Agreement Amendment and allow 10 calendar days to return. Once completed NMO­ 7013 Income Review/Payment Agreement Amendment is received, the Division will email form to DHCFP at dhcfpkatiebeckett@dhcfp.nv.gov. Note: If no signed NMO-7013 Income Review/Payment Agreement Amendment Form is returned, Katie Beckett monthly premium will remain unchanged, and the Division Institutional Unit will take NO NEGATIVE action on case. Households with children who are American Indian (AI)/Alaska Native (AN) are not charged a monthly premium. Child of AI/AN descent are exempt from the premium. Verification of AI/AN descent must be provided to waive the premium. The child’s tribal affiliation should be entered on the Member BAP. Disenrollment will occur if a household is 60 days or two full months past due. DHCFP will notify the Division of households who are 60 days or two full months past due. Staff will be notified with a task in the system when non-payment has occurred. See D-500 Changes for processing non-payment. D-380.1 Division of Health Care Finance and Policy (DHCFP) Determination DHCFP Central Office processes disability determinations and DHCFP district offices complete level of care assessments. After all other eligibility requirements are met, the DHCFP Central Office will determine disability, level of care, medical costs, and if home care is appropriate. DHCFP determinations are made per the Medicaid Operations Manual. Staff or, if appropriate, the Title XIX Social Worker will send Form NMO­ 3010 to DHCFP. DHCFP will notify the district office of the review board's decision of disability and/or final eligibility under 1902(e)(3) on the Home and Community Based Services Waiver Eligibility Status Form NMO-3010. DHCFP will send Katie Beckett Premium invoices/notices to families with detailed information on how to make premium payments. Families with children enrolled in Katie Beckett option are charged a monthly premium based on the family’s monthly taxable income and household size. Premiums are charged per family, not per child. Payment arrangements may be made monthly, annually, or anything in-between with DHCFP. D-380 MAABD APPLICATION PROCESSING KATIE BECKETT Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25