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EIS 2012 - COMPLETING AN APPLICATION FORM FOR NEW APPLICATIONS, REAPPLICATIONS, AND ADD-AN-INDIVIDUAL APPLICATIONS FOR M-AF, M-IC, M-PW, AND M-RF



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        M-AF

        Medicaid Aid to Families and Children

        M-IC

        Medicaid Infants and Children

        M-PW

        Medicaid Pregnant Woman

        M-RF

        Medicaid Refugee Assistance

        17. Do not use the MQB-QI1 field. It does not apply to MAF, MIC, MPW, or MRF.
        18. Enter the HLTH CH? field only for MIC applications using one of the following codes:
          a. “Y” if the MIC application is for NC Health Choice.
          b. “N” if the MIC application is not for NC Health Choice.

          If the aid program/category is MIC, you must enter “Y” or “N” in this field before application disposition. If a “Y” is entered, the application date cannot be earlier than October 1, 1998.

        19. Enter the FAM PLAN? field only for MAF applications using one of the following codes:
          a. “Y” if the MAF application is for Family Planning Medicaid.
          b. “N” if the MAF application is not for Family Planning Medicaid.

    REVISED 03/01/10 - CHANGE NO. 03-10

    II. A. 19. b. (CONT’D)

          If the aid program/category is MAF, you must enter “Y” or “N” in this field before application disposition. If a “Y” is entered, the application date cannot be earlier than October 1, 2005.

        20. Enter “Y” or “N” for C/H INCLUDED.
          a. For new applications and reapplications, mark “Yes” or “No” to indicate if the individual on line 01 is to be INCLUDED IN THE CASE.
          b. For Type “3” and “6” applications, mark “Yes” or “No” to indicate whether the individual on line 01 of the Add-on Application is the Casehead/Payee.
        21. Enter the LINE NUMBER beginning with 01.
        22. Enter the INDIVIDUAL ID for each person to be included on the application.

          NOTE: IF THE ID ENTERED IS UNKNOWN TO THE SYSTEM OR IF THE NUMBER DOES NOT MATCH THAT INDIVIDUAL, THE APPLICATION DOES NOT PROCESS.

        23. Enter the following in the CTZ (Citizenship) field to document citizenship for each individual listed on the DSS-8124. There must be an entry for each individual listed on the DSS-8124.
          a. “Y” Individual is applying for assistance and states he is a U.S. citizen.
          b. “N” Individual is applying for assistance and states he is not a U.S. Citizen.
          c. “X” Casehead is not applying for benefits or individual who states he is a U.S. Citizen and does not have a social security number.
        24. Enter the APPLICATION DATE.
          a. If the MIC application is for NC Health Choice, this date cannot be before 10/01/98.
          b. If the MAF application is for Family Planning, this date cannot be before 10/01/05.

    REISSUED 03/01/10 - CHANGE NO. 03-10

    II. A. (CONT’D)

        25. APPLICANT'S/REPRESENTATIVE'S SIGNATURE
          a. The applicant or his representative must read and understand the statements on the back of the application before he signs the form. If he cannot read or does not understand, explain the statements to him in a manner that he can understand.
          b. The applicant or his representative must sign his name the day he applies. If he cannot sign his name, have him make his mark, "X," on the form. Two persons must witness his mark. The worker's signature serves as one of the witnesses.

          DISPOSITION FIELDS ARE NOT USED IN APPLICATION REGISTRATION. REFER TO THE DENIAL (EIS 2150) AND WITHDRAWAL (EIS 2200) SECTIONS FOR INSTRUCTIONS ON HOW TO DENY OR WITHDRAW THE APPLICATION AT REGISTRATION.

        26. When necessary, a WITNESS SIGNATURE may be entered.
        27. Sign the application in the CASEWORKER SIGNATURE field.
        28. The county director or his designee must sign and date the form in the DIRECTOR'S SIGNATURE and DATE field.

      B. Key the DSS-8124.

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    III. OUTPUTS

      An Application Turnaround is produced overnight when the application is entered and accepted into the system and mailed to the county the next workday.

      NOTE: The name on the 8124I must match Social Security Records. Use the name on the SDX, BENDEX, SOLQ, TPQ, Social Security Card, or Medicare Card. If a discrepancy exists, use the name from the online verification.

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    IV. ADMINISTRATIVE APPLICATIONS

      A. Administrative DSS-8124's do not have to be signed by the applicant. They are used to:

        1. Establish separate cases for which there is a signed application on file for all individuals listed.
        2. Re-establish a case closed in error by processing the DSS-8124 as a reapplication.
        3. Establish automatic coverage for a newborn.
        4. Register a Presumptive Eligibility referral.

    REISSUED 03/01/10 - CHANGE NO. 03-10

    II. A. (CONT’D)

        5. Change the casehead/payee.
        6. Enter other cases or individuals as required by policy.

      B. To complete an administrative DSS-8124:

        1. Enter Application Type “2” (Reapplication), “5” (Reapplication with Retroactive Benefits), or “6” (Add-An-Individual). For automatic newborn coverage, enter Application Type “7” (Application), when a new case is established for a newborn(s) or Application Type “3” (Add-An-Individual) if the newborn is being added to an existing case. For Presumptive Eligibility, enter Application Type “1” (New Application).
        2. Re-enter the individual(s) and data as listed on the original DSS-8124.
        3. Use the application date from the original application.
        4. For M-PW Presumptive Eligibility only cases, use the date the pregnant woman signed the DMA-5032, Presumptive Eligibility Determination, as the application date.

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    V. Dual Eligibility – MEDICALLY NEEDY (MAF-M or MAD-M) and Family Planning (MAF-D)

      When an applicant is potentially eligible for Medically Needy (MAF-M or MAD-M) and Family Planning Medicaid:

    A. Complete a DSS-8124:

        1. Key the DSS-8124 for Medically Needy (MAF-M or MAD-M) by following instructions in I. and II. above. This should be a new application.
        2. Pend the application until the individual meets his/her deductible.

      B. Complete a second new DSS-8124:

        1. Key a second application for Family Planning (MAF-D).
        2. Approve the second application. When the individual’s deductible is met, terminate the Family Planning (MAF-D) case and approve the pended application for full Medicaid.

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