NC DEPARTMENT OF HEALTH AND HUMAN SERVICES EIS MANUAL

ELIGIBILITY INFORMATION SYSTEM EIS 3101

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CHANGES TO MEDICAID CASES

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EIS 3101 – CHANGES TO MEDICAID CASES


I. COMPLETING THE DSS-8125

II. SIGNATURES AND DATE

III. KEY THE DSS-8125.

IV. OUTPUTS


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SPECIAL COVERAGE GROUPS - COMMUNITY ALTERNATIVE PROGRAM

REVISED 02/01/11 – CHANGE NO. 03-11

NOTE: CAP coverage is not terminated by EIS when an individual moves to a new county.

NOTE: When placing the Medicaid of a recipient of CAP services in suspension due to incarceration or placement in an Institution for Mental Disease (IMD), terminate CAP at the end of the current processing month. See instructions below for completing the DSS-8125 to end date the CAP coverage.

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I. COMPLETING THE DSS-8125

REVISED 10/01/12 – CHANGE NO. 01-13

I.A.9.(CONT’D)-(SPECIAL COVERAGE GROUPS – COMMUNITY ALTERNATIVE PROGRAM)

REISSUED 10/01/12 – CHANGE NO. 01-13

I. (CONT'D)-(SPECIAL COVERAGE GROUPS – COMMUNITY ALTERNATIVE PROGRAM)

      10. Enter the SPECIAL COVERAGE GROUP BEGIN DATE. Enter the date coverage begins. Must be MMDDYY and can be any day of the month. The date must not be before the application date. CAP cannot be posted to a period of time that is authorized in an aid program that is not eligible for CAP, i.e. MQB.
      11. When CAP ends, enter the SPECIAL COVERAGE GROUP CODE, the BEGIN DATE, and the END DATE. The END DATE must be after the BEGIN DATE and must be the last day of the month. The date must not be earlier than the last day of the month prior to the ongoing month.

    B. CHANGING CAP COVERAGE

      1. When CAP coverage changes from one coverage group to another coverage group:

        You must end CAP coverage in one coverage group to change to another coverage group, for instance, changing from CAP/DA to CAP/MR.

        a. To end CAP coverage in the old coverage group, enter the old SPECIAL COVERAGE GROUP CODE, BEGIN DATE, and END DATE. The END DATE must be after the BEGIN DATE and must be the last day of the month prior to the ongoing month.
        b. Enter the new SPECIAL COVERAGE GROUP CODE and BEGIN DATE. The BEGIN DATE cannot be earlier than the first day of the ongoing month.
      2. Changes in CAP coverage within a coverage group:

        You must end CAP coverage at one level of care to change to another level of care, for instance, changing from CAP/DA-ICF level of care to CAP/DA-SNF level of care.

        a. When CAP coverage changes from a lower level of coverage to a higher level enter the old SPECIAL COVERAGE GROUP CODE, BEGIN DATE, and END DATE. The END DATE must be after the BEGIN DATE and must be the last day of the month prior to the on-going month. Enter the new SPECIAL COVERAGE CODE and BEGIN DATE. The BEGIN DATE can be any day of the month and can be earlier than the ongoing month since greater coverage overlays lesser coverage in EIS Individual Eligibility History (IE).

REVISED 10/01/12 – CHANGE NO. 01-13

I. (CONT'D)-(SPECIAL COVERAGE GROUPS – COMMUNITY ALTERNATIVE PROGRAM)

        b. When CAP coverage changes from a higher level of coverage to a lower level, enter the old SPECIAL COVERAGE GROUP CODE, BEGIN DATE, and END DATE. The END DATE must be after the BEGIN DATE, and must be the last day of the month prior to the ongoing month. Enter the new SPECIAL COVERAGE CODE and BEGIN DATE. The BEGIN DATE cannot be earlier than the first day of the ongoing month.
        c. No changes permitted retroactively between the Comprehensive Waiver (CM-ICF-MR level of care) and the Supports Waiver (C2-ICF-MR level of care).

    C. DO NOT ENTER the following fields on the DSS-8125:

      1. Verification Indicator
      2. Application Data
      3. Termination Data
      4. Payment Date
      5. Medicaid Effective Date
      6. Retro MA Data
      7. Work Experience
      9. Educational Level
      10. Issue CRD
      11. Disability Indicator (DIS)

      NOTE: ALL OTHER FIELDS ARE OPTIONAL. A DETAILED EXPLANATION OF EACH FIELD IS INCLUDED IN “OTHER CHANGED DATA”.

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II. SIGNATURES AND DATE

    A. Enter the DATE COMPLETED.

    B. Sign the DSS-8125 in the WORKER'S SIGNATURE field.

    C. The county director or his designee must sign the form in the DIRECTOR'S SIGNATURE field.

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III. KEY THE DSS-8125.

REISSUED 10/01/12 – CHANGE NO. 01-13

I. (CONT'D)-(SPECIAL COVERAGE GROUPS – COMMUNITY ALTERNATIVE PROGRAM)

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IV. OUTPUTS

    When the DSS-8125 processes successfully, the following are received:

    A. Case Profile

      An updated Case Profile is produced the night the change processes and is mailed to the county the following workday for non-SSI cases and SSI/SAAD and SSI/AAF cases. The Case Profile reflects the ongoing processing month.

    B. Caseworker Supervisor Report

      All changes completed by an IMC are reported on the Caseworker Supervisor Report. The number of actions completed is determined from the WORKER NUMBER.

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    V. FOR ANY CHANGES NOT LISTED, SEE ”OTHER CHANGED DATA”

EXAMPLE #1

POST CAP AT APPLICATION APPROVAL

Ms. Jones is active MQB. She has an MAA application dated 8-10-95 pending to meet her CAP deductible. Her CAP Plan of Care/FL-2 is approved effective 9-15-95.

EIS INDIVIDUAL ELIGIBILITY HISTORY displays:

On 10-10-95, she presents medical bills to meet the CAP deductible effective September 18. She meets the October deductible effective October 3.

Close the MQB case effective 10-31-95. The next day, approve the MAA application in deductible status effective 11-01-95. Post the CAP SPECIAL COVERAGE CODE and BEGIN DATE on the 8125 entered for the application approval.

EIS INDIVIDUAL ELIGIBILITY HISTORY displays:

REISSUED 10/01/12 – CHANGE NO. 01-13

I. (CONT'D)-(SPECIAL COVERAGE GROUPS – COMMUNITY ALTERNATIVE PROGRAM)

On the DB/PML screen, authorize MAA 9-18-95 through 9-30-95 and 10-3-95 through 10-31-95 using the EIS Case ID in IE for that period of time. (Issue Card = N)

EIS INDIVIDUAL ELIGIBILITY HISTORY displays:

On the same day eligibility is authorized on the DB/PML screen, enter an 8125 to post CAP for the same period of time using the EIS Case ID displayed in IE for that period of time. In SPECIAL COVERAGE #1 field, enter the CAP SPECIAL COVERAGE CODE and BEGIN DATE (09/18/95) and END DATE (09/30/95). In SPECIAL COVERAGE #2 field, enter the CAP SPECIAL COVERAGE CODE and BEGIN DATE (10/03/95) and END DATE (10/31/95).

When the 8125 processes overnight, EIS INDIVIDUAL ELIGIBILITY HISTORY displays:

REISSUED 10/01/12 – CHANGE NO. 01-13

I. (CONT'D)-(SPECIAL COVERAGE GROUPS – COMMUNITY ALTERNATIVE PROGRAM)

In November, bills are received to meet the CAP deductible November 4. Use the DB/PML screen to authorize 11-4-95 through 11-30-95 using the EIS Case ID displayed in IE for that period of time.

EIS INDIVIDUAL ELIGIBILITY HISTORY displays:

REVISED 10/01/12 - CHANGE NO. 01-13

(CONT’D) - SPECIAL COVERAGE GROUPS - COMMUNITY ALTERNATIVE PROGRAM)

EXAMPLE #2

POST CAP AT CHANGE IN SITUATION INCLUDING AID PROGRAM TRANSFER:

Ms. Jones is active MQB. Her CAP Plan of Care/FL-2 is approved effective
9-15-95.

EIS INDIVIDUAL ELIGIBILITY HISTORY displays:

On 10-10-95, she presents medical bills to meet the CAP deductible effective September 18. She meets the October deductible effective October 3. Transfer the MQB case to MAA effective 11-01-95 in deductible status.

EIS INDIVIDUAL ELIGIBILITY HISTORY displays:

REVISED 10/01/96 - CHANGE NO. 02-96

EXAMPLE #2 (CONT’D)

(SPECIAL COVERAGE GROUPS - COMMUNITY ALTERNATIVE PROGRAM)

On the DB/PML screen authorize MAA 9-18-95 through 9-30-95 and 10-3-95 through 10-31-95.

EIS INDIVIDUAL ELIGIBILITY HISTORY displays:

On the same day eligibility is authorized on the DB/PML screen, enter an 8125 to post CAP for the same period of time using the EIS Case ID displayed in IE for that period of time. In SPECIAL COVERAGE #1 field, enter the CAP SPECIAL COVERAGE CODE and BEGIN DATE (09/18/95) and END DATE (09/30/95). In SPECIAL COVERAGE #2 field, enter the CAP SPECIAL COVERAGE CODE and BEGIN DATE (10/03/95) and END DATE (10/31/95). In SPECIAL COVERAGE #3 field, enter the CAP SPECIAL COVERAGE CODE and BEGIN DATE (11/01/95). Do not enter an END DATE in SPECIAL COVERAGE field #3.

When the 8125 processes overnight, EIS INDIVIDUAL ELIGIBILITY HISTORY displays:

REVISED 10/01/96 - CHANGE NO. 02-96

EXAMPLE #2 (CONT’D)

(SPECIAL COVERAGE GROUPS - COMMUNITY ALTERNATIVE PROGRAM)

In November, bills are received to meet the CAP deductible November 4. Use the DB/PML screen to authorize 11-4-95 through 11-30-95 using the EIS Case ID displayed in IE for that period of time.

EIS INDIVIDUAL ELIGIBILITY HISTORY displays:

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