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NC DEPARTMENT OF HEALTH AND HUMAN SERVICES EIS MANUAL

ELIGIBILITY INFORMATION SYSTEM EIS 4000

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CODES APPENDIX D – SPECIAL ASSISTANCE CODES

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EIS 4000 - CODES APPENDIX D – SPECIAL ASSISTANCE CODES

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EIS 4000 - CODES APPENDIX D – SPECIAL ASSISTANCE CODES

CHANGE CODES - ADEQUATE SPECIAL ASSISTANCE CHANGES
REISSUED 01/01/06 - CHANGE NO. 03-06

DSS-8110A

Based on the adequate change code entered on the DSS-8125, EIS will produce a notice to say:

REVISED 01/01/06 - CHANGE NO. 03-06

SA ADEQUATE CHANGE NOTICE TEXT (CONT'D)

REVISED 01/01/06 - CHANGE NO. 03-06

SA ADEQUATE CHANGE NOTICE TEXT (CONT'D)

REVISED 09/01/06 - CHANGE NO. 02-07

SA ADEQUATE CHANGE CODES (CONT'D)

CAP CASES

MEDICARE A AND/OR B INDICATOR CHANGE (SAA AND SAD)

REISSUED 09/01/06 - CHANGE NO. 02-07

CHANGE CODES - TIMELY SPECIAL ASSISTANCE CHANGES

DSS-8110A

Based on the timely change code entered on the DSS-8125, EIS will produce a notice to say:

REVISED 09/01/06 - CHANGE NO. 02-07

SA TIMELY CHANGE CODES (CONT'D)

REVISED 01/01/06 - CHANGE NO. 03-06

SA TIMELY CHANGE CODES (CONT'D)

CAP CASES

MEDICARE A AND/OR B INDICATOR CHANGE (SAA AND SAD)

REISSUED 01/01/06 - CHANGE NO. 03-06

REDETERMINATION NOTICES WITH NO CHANGES IN THE CASE

DSS-8108A

Based on change code "01" entered on the DSS-8125, EIS will produce a notice to say:

CAP CASES

SAA/SAD Cases With Existing (Active) CAP Coverage

When completing a review for an SAA/SAD case with existing CAP Coverage, DO NOT enter a CHANGE CODE or NOTICE OVERRIDE. An automated notice is not produced. Complete a manual notice according to policy requirements.

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

DISPOSITION CODES - SPECIAL ASSISTANCE APPROVALS

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

SA ONGOING APPROVALS (CONT'D)

      A1

      "Your application has been approved because you meet all eligibility requirements." (Section 3100)

       

      A2

      "You are not eligible for the month of application because your assets exceed the reserve limit found in Section 3130 of the SA Manual. However, you have been approved for subsequent months because you meet all eligibility requirements." (Section 3100)

       

      A3

      "You are not eligible for the month of application because your income was too high to receive SA. However, you have been approved for subsequent months because you meet all eligibility requirements." (Section 3100)

       

      A4

      "You are not eligible for the month of application because you were not in a domiciliary care facility. However, you have been approved for subsequent months because you meet all eligibility requirements." (Section 3100)

       

      A5

      "You are not eligible for the month of application because you lived or received assistance in another state. However, you have been approved for subsequent months because you meet all eligibility requirements." (Section 3100)

       

      A6

      "Other" (Manual Notice Required)

         

      B8

      “The following individual(s) is approved for Medicaid for the months of ___ thru ___. You must provide verification of citizenship and/or identity to continue to receive Medicaid. If documentation is not received, your Medicaid will be terminated.” (Section 3245)

CAP CASES

When completing a DSS-8125 to approve SAA or SAD with CAP Coverage, enter "Y" in the NOTICE OVERRIDE field. Complete a manual notice. If the NOTICE OVERRIDE field is blank, an automated notice will be produced; however, there will be no CAP information on the notice.

REVISED 10/01/09 - CHANGE NO. 01-10

SA APPROVALS (CONT'D)

OPEN/SHUT APPROVALS (APPLICATION TYPES 1, 2, AND 6)

    1. The application disposition code entered will determine the message to be printed on the DSS-8108A.

    2. The text will be:

      a. For SAA and SAD applications:

        "You will receive the following benefits for the months listed:"

        MMYY $_____

        MMYY $_____

        (Name and Individual ID Number)

        $______ This is your monthly payment amount.

        MMYY This is the date your monthly payment begins.

        When RETRO MA1 is present the following text will be printed:

        MMYY to MMYY This is additional Medicaid coverage you will receive.

        When Buy-In is present the following text will be printed:

        MMDDYY The State will pay your Medicare Part B premium.

        When the termination reason and date are present:

        MMYY This is the last month you will receive a payment and Medicaid coverage or this is the last month you will receive a payment, Medicaid coverage, and your Medicare Part B premium paid by the State.

            The termination reason entered determines the reason text printed.

        When a “Y” is keyed for Medicare A and/or B on the DSS-8125, the following sentence will be printed on the approval notice.

        “If you receive Medicare, Medicare is responsible for your prescriptions.”

REISSUED 10/01/09 - CHANGE NO. 01-10

SA OPEN/SHUT APPROVALS (CONT'D)

      b. For SCD applications:

        "You will receive the following benefits for the months listed:"

        MMYY $_____

        MMYY $_____

        $_____ This is your monthly payment amount.

        MMYY This is the date your monthly payment begins.

        When the termination reason and date are present:

        MMYY This is the last month you will receive a payment.

        The termination reason entered determines the reason text printed.

            OPEN/SHUT APPROVAL CODE AND TEXT

      A7

      "Your application has been approved because you meet all eligibility requirements." (Section 3100)

CAP CASES

When completing a DSS-8125 to approve SAA or SAD with CAP Coverage, enter "Y" in the NOTICE OVERRIDE field. Complete a manual notice. If the NOTICE OVERRIDE field is blank, an automated notice will be produced; however, there will be no CAP information on the notice.

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

DISPOSITION CODES - SPECIAL ASSISTANCE DENIALS

    1. The reason code entered as the application disposition reason will determine the text to be printed on the automated DSS-8109.

    2. For SAA, SAD, and SCD applications, the text will be:

      "This is to notify you that your application for ______ has been denied.

    3. Followed by:

      "The reason for this action is: _____________________________________

    4. The state regulations applied to make this decision are found in Section _______ of the SA Manual.

      RESIDENCE REQUIREMENTS

    D2
    You do not live in North Carolina. (Section 3250)
       
    G8
    You are living in a public, non-medical institution. (Section 3100)
       
    G9
    You are not living in a rest home or group home. Therefore, you are not eligible to receive Special Assistance. (Section 3100)
       
    H7
    You moved to another state. (Section 3250)

      RESERVE REQUIREMENTS

    G4
    You and/or your spouse have cash, property, bank accounts, life insurance policies, and vehicles greater than allowed for you to receive Special Assistance. (Section 3200)
       
    M2
    You sold, gave away, or assigned real property to someone else. (Manual Notice Required). (Section 3200)
       
    M3
    You sold, gave away, or assigned personal property to someone else. (Manual Notice Required). (Section 3200)

      INCOME REQUIREMENTS

    G5
    You and/or your spouse have net income greater than allowed to receive Special Assistance. (Section 3100)

      DISABILITY REQUIREMENTS

    H0
    Your condition does not meet the State definition of disability/blindness. (SCD - Appendix C)
       
    H1
    Your condition does not meet the SSI definition of disability/blindness. (SAD - Section 3100)

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

SA DENIAL CODES (CONT'D)

          CITIZENSHIP/IDENTITY

    N1

    You did not provide documentation of citizenship and/or identity. (Individual(s) previously received benefits while trying to resolve citizenship code “97”) (Section 3245)

      OTHER REQUIREMENTS

    C4
    You have moved and we are unable to locate you. (Section 3110)
       
    G6
    You are not a U.S. citizen or qualified Alien. (Section 3240)
       
    G7
    You do not meet the age requirement. (Section 3230)
       
    H2
    You did not apply for SSI. (Section 3100)

    H3

    You are already receiving assistance in another case, county, or state. (Section 3100)

       

    H4

    You will not allow us to match your social security number against other agencies' records. (Section 3400)

       

    H5

    Denied after twelve months because we did not receive the information needed to establish eligibility for Special Assistance. (Section 3100)

       

    H6

    Eligibility does not exist due to death of the applicant. (Section 3100)

       

    H9

    You have not provided necessary information to document citizenship and/or identity. (Section 3240)

       

    M1

    Other (Manual Notice Required).

       

    M5

    Administrative Denial

REISSUED 10/01/09 - CHANGE NO. 01-10

DISPOSITION CODES - SPECIAL ASSISTANCE WITHDRAWALS

AUTOMATED WITHDRAWAL NOTICES ARE PRODUCED FOR SPECIAL ASSISTANCE.

    1. The reason code entered as the application disposition reason will determine the text to be printed on the automated DSS-8191-W.

    2. For SAA, SAD, and SCD applications, the text will be:

      "This is to notify you that your application for _____ has been withdrawn."

    3. Followed by:

      "The reason for this action is:

      _______________________________________________

    4. The state regulations applied to make this decision are found in Section _______ of the SA Manual.

    WITHDRAWAL CODES ARE AS FOLLOWS:

    W1

    You asked that your application be withdrawn. (Section 3110)

       

    W5

    You asked that your application be withdrawn rather than allow us to match your social security number against other agencies' records. (Section 3400)

REVISED 10/01/09 - CHANGE NO. 01-10

TERMINATION CODES - ADEQUATE SPECIAL ASSISTANCE TERMINATIONS

DSS-8110A

Based on the adequate termination code entered on the DSS-8125, EIS will produce a notice to say:

    1. "Adequate"

    2. The Change Which Will Take Place

      a. For SAA and SCD cases:

        MMDDYY This is the last month you will receive a payment.

            All Medicaid benefits will stop.

        When Buy-In is present and the Medicaid Class is "C," the following text will be printed:

        MMDDYY (Same as termination date) Medicaid will stop paying your Medicare Part B premium.

        If an individual(s) becomes ineligible for Medicaid, do not throw away the card. The individual may become eligible again and will need the card.

      b. For SCD cases:

        MMDDYY This is the last month you will receive a payment.

    3. A reason that will correspond to one of the reasons listed below. Then the sentence:

      "State rules supporting this action are found in Section _____ of the SA Manual."

    4. "The change is effective on MMDDYY. However, you have until MMDDYYYY, which is 10 workdays from the date of this letter to request a hearing."

    50
    Notice Text - Do not enter.
       
    51
    Recipient is deceased. (Section 3100)
       
    52
    You have been admitted to an institution and no longer qualify for assistance. (Section 3100)
       
    53
    You have requested in writing that your assistance be terminated. (Section 3110)

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

SA ADEQUATE TERMINATION CODES (CONT'D)

    54
    You have been placed in a Medicaid nursing facility or in long-term hospitalization. (Section 3100)
       
    55
    We are unable to locate you. Agency mail sent to you has been returned by the post office indicating no known forwarding address. (Section 3110)
       
    56
    You are now receiving benefits in another state. (Section 3100)
       
    57
    Other (Manual Notice Required)
       
    6Q
    You have not provided necessary information to document citizenship and/or identity. (Section 3240)
       
    6R
    You have failed to provide documentation of citizenship and/or identity. (Individual(s) previously received benefits while trying to resolve citizenship code “97’) (Section 3245)

CAP CASES

    1. SAA/SAD Cases With Existing (Active) CAP Coverage

      When terminating an SAA/SAD case with existing CAP coverage, DO NOT enter a NOTICE OVERRIDE. An automated notice is not produced. Complete a manual notice according to policy requirements.

    2. SA/SAD Cases Without Existing (Active) CAP Coverage

      When completing a DSS-8125 to terminate an SAA/SAD case and you are also entering CAP information, enter "Y" for NOTICE OVERRIDE. Complete a manual notice. If the NOTICE OVERRIDE field is blank, an automated notice will be produced; however, there will be no CAP information on the notice.

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

TERMINATION CODES - TIMELY SPECIAL ASSISTANCE TERMINATIONS

DSS-8110A

Based on the timely termination code entered on the DSS-8125, EIS will produce a notice to say:

    1. "Timely"

    2. What the Change Will Be

      a. For SAA and SAD cases:

        MMDDYY This is the last month you will receive a payment.

            All Medicaid benefits will stop.

        When Buy-In is present and the Medicaid Class is "C," the following text will be printed:

        MMDDYY (Same as termination date) Medicaid will stop paying your Medicare Part B premium.

        If an individual(s) becomes ineligible for Medicaid, do not throw away the card. The individual may become eligible again and will need the card.

      b. For SCD cases:

        MMDDYY This is the last month you will receive a payment.

    3. A reason that will correspond to one of the reasons listed below. Then the sentence:

      "State rules supporting this action are found in Section ______ of the SA Manual."

    4. "The change will be effective on MMDDYY, which is 10 workdays from the date of this letter, unless you ask for a hearing on or before that date."

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

SA TIMELY TERMINATION CODES (CONT'D)

      INCOME

    04
    You and/or your spouse have net income greater than allowed to receive Special Assistance (Section 3210)
       
    05
    You and/or your essential person have net income greater than allowed to receive Special Assistance. (SCD) (Section 3210)
       
    10
    You did not cooperate in determining the amount of earned or unearned income you might be eligible to receive. (Section 3210)

      RESERVE

    15
    You and/or your spouse have cash, property, bank accounts, life insurance, vehicles, and/or other assets greater than allowed to receive Special Assistance. (SAA and SAD) (Section 3200)
       
    16
    You and/or your essential person have cash, property, bank accounts, life insurance, vehicles, and/or other assets greater than allowed for you to receive Special Assistance. (SCD) (Section 3200)
       
    17
    You sold, gave away, or assigned real property to someone else. (Section 3200) Manual Notice Required.
       
    18
    You sold, gave away, or assigned personal property to someone else. (Section 3200) Manual Notice Required.

      OTHER FACTORS

    01
    You no longer live in North Carolina (Section 3250)
       
    02
    Notice Text - Do not enter.
       
    03
    You are no longer living in a rest home or group home. Therefore, you are not eligible to receive Special Assistance. (SAA and SAD) (Section 3100)

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

SA TIMELY (OTHER FACTORS TERMINATION CODES (CONT'D)

    06
    You have moved and we are unable to locate you. (Section 3110)
       
    07
    You are no longer disabled and therefore no longer qualify for Special Assistance. (Section 3100)
       
    08
    You did not provide the information requested to determine your continuing eligibility. (Section 3110)
       
    09
    You did not come in for your review appointment and we do not have the information necessary to determine your continuing eligibility. (Section 3320)
       
    11
    The completed contribution letters have not been returned. (Section 3210)
       
    12
    You refused to allow us to match your social security number with other agencies' records. (SAA and SAD) (Section 3400)
       
    13
    I have not received information needed from a collateral source to determine your continuing eligibility. (Section 3320)
       
    14
    You did not provide your wage stubs or the completed wage form by the deadline. (Section 3210)
       
    19
    You have moved to a county that does not participate in the SCD Program. (SCD) (Appendix C)
       
    20
    You have requested that your assistance be terminated. (No written request) (Section 3320)
       
    21
    You are eligible for SSI. (SCD) (Appendix C)
       
    22
    You are now age 65. Therefore, you are not eligible to receive in the SCD program. You may apply for Medicaid. (SCD) (Appendix C)
       
    2Q
    You have not provided necessary information to document citizenship and/or identity. (Section 3240)
       
    2R
    You have failed to provide documentation of citizenship and/or identity. (Individuals previously received benefits while trying to resolve citizenship code “97”) (Section 3245)

REISSUED 09/01/06 - CHANGE NO. 02-07

AUTOMATIC EIS TERMINATIONS (SYSTEM ASSIGNED - DO NOT ENTER)

    67
    Program and/or category transfers
       
    68
    County reassignment

CAP CASES

    1. SAA/SAD Cases With Existing (Active) CAP Coverage

      When terminating an SAA/SAD case with existing CAP coverage, DO NOT enter a NOTICE OVERRIDE. An automated notice is not produced. Complete a manual notice according to policy requirements.

    2. SA/SAD Cases Without Existing (Active) CAP Coverage

      When completing a DSS-8125 to terminate an SAA/SAD case and you are also entering CAP information, enter "Y" for NOTICE OVERRIDE. Complete a manual notice. If the NOTICE OVERRIDE field is blank, an automated notice will be produced; however, there will be no CAP information on the notice.

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