NC DEPARTMENT OF HEALTH AND HUMAN SERVICES EIS MANUAL

ELIGIBILITY INFORMATION SYSTEM EIS 4300

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NC HEALTH CHOICE – ONGOING CASE MAINTENANCE - PART FIVE

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NC HEALTH CHOICE – ONGOING CASE MAINTENANCE - PART FIVE


V.E.(CONT’D)

VII. (CONT’D)

VIII. A. (CONT’D)

VIII. A. (CONT’D)

IX. (CONT’D)

XII. (CONT’D)


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EIS 4300 - NC HEALTH CHOICE – ONGOING CASE MAINTENANCE
PART FIVE

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

Recipients of NC Health Choice are evaluated for Medicaid at
re-enrollment. If the individual is eligible for Medicaid, transfer the NC Health Choice case to MIC-N, MIC-1, or MAF. If eligible for any other aid program/category, the individual is terminated or deleted from NC Health Choice and a new application is entered in EIS.

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

V. (CONT’D)

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

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V.E.(CONT’D)

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

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VII. (CONT’D)

    D. At the end of the 12-month extended coverage period (MIC/L), EIS automatically terminates the case on PULL night in the 12th month for all recipients who paid the premiums payment for the entire 12 months.

    E. A notice is generated for all terminations with the reason for termination.

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    VIII. Premium Payment Screen

    A. If a family that is in the optional extended coverage group reapplies and is found eligible for either MIC-N or NCHC class A/J/K/or S, the caseworker must verify premium payments before approving the case. To verify premiums, the caseworker must complete the following steps:

      1. From the EIS Menu (Inquiry) Screen, Key “PP” and the Medicaid Individual Number (MID). Then press enter.

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

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VIII. A. (CONT’D)

      2. The following information will display:
          a. Individual ID Number
          b. Recipient Name
          c. Recipient Date of Birth
          d. Case ID Number
          e. County Number
          f. Certification Period
          g. Payment Data Created
          h. Premium Payment End Date
          i. Monthly Premiums Amount
          j. Date Payment Post
      3. The Premium Payment Screen will display each month in which premiums were received, the amount received, the date premium payments were posted, and a code representing the DMA worker who entered the information. The caseworker would use the last month that a premiums payment was received to determine the paid-to-date.

      Example: If a payment amount for 12/31/2011 was the last month entered, this indicates that the recipient has paid premiums through 12/31/2011.

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

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VIII. A. (CONT’D)

      If each month displays a zero amount, the recipient was approved for the Optional Extended Group but no premiums have been made.

      Please Note: The caseworker can view another individual by entering “PP” and the Medicaid Individual Number (MID) without exiting the screen.

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

VIII. A. (CONT’D)

      4. If the caseworker enters an Medicaid Individual Number (MID) for a recipient who was not approved for Optional Extended Coverage, the Premium Payment Screen will list the individual information at the top of page but the message “Individual Is Not In Extended Coverage Group” will display.

    B. Key “PF2” to Exit.

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    IX. CHANGES TO NC HEALTH CHOICE CASES WHICH MAY RESULT IN DELETION/TERMINATION

      NC Health Choice may be terminated or the individual deleted from the case for any one of the following reasons:

      A. The recipient acquires comprehensive health insurance.

      B. The recipient moves out of North Carolina.

      C. The recipient is deceased.

      D. The recipient voluntarily requests termination of assistance.

      E. The recipient turns age 19.

      F. The recipient is incarcerated.

      G. The recipient becomes eligible for Work First.

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

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IX. (CONT’D)

      H. A child is removed from the home by the department of social services for placement purposes and is eligible for H-SF or I-AS.

        1. When a child is removed from the home by DSS and placed in foster care, terminate NC Health Choice if the child is the only individual on the case and approve as H-SF or I-AS. If the NC Health Choice has other individuals on the case, delete the individual from NC Health Choice and approve H-SF or I-AS.
        2. If the child returns to the home within the original 12-month enrollment period, terminate H-SF or I-AS. Complete an administrative re-application with the original date of application to authorize NC Health Choice (or add to existing a.u.) for the remainder of the original 12-month enrollment period. The original date of application and original certification from date must be entered into EIS in order for the Division of Medical Assistance (DMA) to calculate the correct 12-month enrollment period. Authorize effective the month after Medicaid terminates.

      I. A child is approved for SSI Medicaid. EIS automatically terminates/deletes the child and authorizes for M-AD.

      J. If the child is subsequently terminated from SSI Medicaid during the same 12-month enrollment period, complete an administrative
      re-application to authorize NC Health Choice (or add to existing a.u.) for the remainder of the enrollment period. The original date of application and original certification from date must be entered into EIS in order for the Division of Medical Assistance (DMA) to calculate the correct 12-month

        enrollment period. Authorize effective the month after Medicaid terminates.

      K. The recipient becomes eligible for CAP services or Medicaid for payment of long term care.

      L. Citizenship/Identity has not been verified.

      M. Monthly Premium Payment for Optional Extended Coverage is

Not paid.

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    X. INDIVIDUALS PLACED IN LONG TERM CARE/ICF-MR

      If the recipient is placed in a long term care facility, evaluate eligibility for Medicaid. Delete or terminate the individual from the NC Health Choice case if the individual is Medicaid eligible. If the individual is ineligible for Medicaid, eligibility continues as NC Health Choice for the remainder of the enrollment period.

      Contact the Claims Analysis Section at DMA (Refer to EIS 1200 – STATE OFFICE CONTACTS) if the child is eligible for Medicaid and eligibility needs to be posted for months in which the recipient was authorized for NC Health Choice.

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

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    XI. INDIVIDUAL BECOMES PREGNANT

      A. Complete an eligibility determination to assure that the recipient is eligible for Medicaid. Verify pregnancy and document eligibility in the case record.

      B. Send adequate notice to terminate NC Health Choice.

        EXCEPTION: IF THE INDIVIDUAL NEEDS PREGNANCY RELATED MEDICAID FOR A RETRO PERIOD ONLY, AND CONTINUES TO BE ELIGIBLE FOR NCHC ONGOING, DO NOT TERMINATE THE NCHC CASE. COMPLETE AN OPEN/SHUT APPLICATION FOR THE MEDICAID COVERAGE AND CONTACT CLAIMS TO DO THE OVERLAY OF ELIGIBILITY.

      C. Treat as an administrative application. Enter an unsigned 8124 in EIS. The date of application is the date the recipient requests coverage.

      D. Approve ongoing eligibility after the NC Health Choice case terminates. For any months authorized for Medicaid where the individual was already covered under NCHC, the IE will continue to display the NCHC information. Do not attempt to update the IE screen in EIS for months already covered by NC Health Choice. This must be corrected by claims.

      E. Contact the Claims Analysis Unit in DMA (EIS 1200 – STATE OFFICE CONTACTS) if “retroactive” coverage of a pregnancy related service is needed. A Claims analyst will take the information necessary to provide coverage.

      F. Refer further inquiries about pregnancy related services to Claims Analysis.

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    XII. SOCIAL SECURITY NUMBER CHANGES OR SSN IS ADDED TO THE CASE

      It is important that social security numbers be entered correctly in EIS when a case is dispositioned. Take the following steps to ensure the correct SSN is entered in EIS for NCHC recipients.

      Verify each child’s SSN by using the SOLQ process. Refer to EIS 1107 – STATE ONLINE QUERY/THIRD PARTY QUERY. Document findings in the case record.

      A. Check the SSN keyed for ID assignment. Verify that the correct SSN has been keyed and that it belongs to the child. Verify that the numbers have not been transposed.
      B. Before keying an approval for NCHC, or releasing an 8125 that may have been placed on hold because of a second party review, verify again that all children have the correct SSNs by reviewing the 8124 online in EIS. This can be done by using the “AD” function to avoid deleting the pending 8125.

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XII. (CONT’D)

      C. If it is found that a child’s SSN was keyed incorrectly and the child is already receiving NCHC, changes can be made using the Name Change (NC) function.

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    XIII. INCORRECT EFFECTIVE DATE FOUND AFTER APPROVAL

      Effective dates for NC Health Choice cases that need to be earlier than originally entered in EIS can be corrected by doing an open/shut application for individuals with benefits months of October 1, 2011 or later. For benefits months prior to October 1, 2011, the caseworker must call EIS for instructions. Refer to EIS 1200 – STATE OFFICE CONTACTS.

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    XIV. CHANGE MEDICAID CLASSIFICATION TO/FROM “J” “K” “S” or “A” (includes changes from j, k, s, or A to mic-n, MIC-1, or maf)

      A. At Re-enrollment

        A change in Medicaid class to another Medicaid class is allowed.

      B. During the 12-month Enrollment Period

        If a NCHC case is approved or re-enrolled in an incorrect Medicaid class in error, you may change the Medicaid Classification using the following instructions.

        1. Do not enter a change code on the 8125. An automated notice will NOT be produced.
        2. The effective date will always be the ongoing (EIS Processing) month.

          NOTE: IF THE ERROR IS FOUND WITHIN TWO MONTHS OF
          RE-ENROLLMENT, THE CHANGE MUST BE MADE AT
          RE-ENROLLMENT.

      C. For policy information prior to keying this transaction into EIS, refer to MA-3255 – NC HEALTH CHOICE.

CHANGES IN HOUSEHOLD SITUATION – ATTACHMENT

 

Use this chart to determine appropriate action when a change in situation occurs

which may affect a NC Health Choice household.

TYPE OF CHANGE

REACTION

REQUIRED ?

COMMENTS

Address of entire assistance unit changes

Yes

Change address in EIS

NOTE: A NC Health Choice case MUST have a North Carolina address. If any other State is entered, an error message displays.

NC Health Choice child leaves the home; other children remain:

The child moves into household not authorized for NC Health Choice

The child moves into another NC Health Choice household

No

No

No

No change in case until re-enrollment. Child remains in the assistance unit.

Evaluate eligibility at re-enrollment.

At end of child’s enrollment period, add to remainder of NC Health Choice period in new household if the child is ineligible for Medicaid. Update needs unit and maintenance amount (if necessary). Do not change classification or income.

Child not authorized for NC Health Choice or Medicaid enters NC Health Choice household

Yes

Evaluate for Medicaid. If ineligible for Medicaid add to NC Health Choice case. Update needs unit and maintenance amount. Do not change income or classification.

Child receiving Medicaid has change in situation and Medicaid is terminated.

Yes

If no NC Health Choice case for household, evaluate child for NC Health Choice. If eligible, approve administrative application for NC Health Choice.

If others in household already receiving NC Health Choice, and MA child does not have comprehensive insurance, complete add-on (type 6/administrative) application to approve NC Health Choice for the child. Update needs unit and maintenance amount (if necessary). Do not change classification or income.

One child is deleted (no longer eligible) from NC Health Choice case which has more than one child.

Yes

In EIS, adjust needs unit and maintenance amount (if necessary). Do not change classification or income.

TYPE OF CHANGE

REACTION

REQUIRED ?

COMMENTS

Budget unit member not authorized for NC Health Choice leaves the home permanently.

No

Evaluate eligibility at re-enrollment.

Family moves to another county

Yes

Complete county transfer in EIS. 2nd county does not have to review until re-enrollment.

Income Increases:

above 150% of FPL

above 200% of FPL

No

No change until re-enrollment.

Income decreases to below MIC limit

No

No change until end of enrollment period

Child moves out of state

Yes

Terminate if only member in case. Delete if other children are in the NC Health Choice case. Update needs unit and maintenance amount (if necessary). Do not change classification or income.

Child acquires comprehensive health insurance (including Medicare)

Yes

Follow instructions for child moves out of state.

Child dies

Yes

Follow instructions for child moves out of state.

Child is incarcerated

Yes

Follow instructions for child moves out of state.

Child becomes eligible for Work First

Yes

Follow instructions for child moves out of state.

Child is removed by DSS and is eligible for HSF/IAS.

Yes

Delete or Terminate. Approve HSF/IAS.

If the child is later returned to parental custody during the NC Health Choice enrollment period-complete administrative re-application (with original date of application) to authorize with original enrollment period; effective date of coverage is the month following month of HSF/IAS termination.

TYPE OF CHANGE

REACTION

REQUIRED ?

COMMENTS

Child becomes SSI Medicaid eligible

Yes

System will authorize child for Medicaid. If other children remain in the NC Health Choice case, change the # in the needs unit and maintenance amount (if necessary). Do not change classification or income.

If child’s SSI stops during original NC Health Choice enrollment period, complete administrative
re-application (with original date of application) to authorize with original enrollment period; effective date of coverage is the month following month of SSI MA termination.

Head of Household requests termination

Yes

Terminate case.

Child marries

No

Leave in the NC Health Choice case.

Child turns age 19

Yes

Delete or terminate child. Evaluate for other coverage.

Child enters Long Term Care

Yes

Evaluate for Medicaid. If eligible, delete or terminate NC Health Choice and approve Medicaid. If ineligible for Medicaid, continue NC Health Choice coverage.

NC Health Choice recipient becomes pregnant

Yes

Evaluate for Medicaid. If eligible ongoing, delete or terminate NC Health Choice and approve ongoing Medicaid. If eligible for retro coverage only, complete an open shut application for the Medicaid coverage. Contact Claims Analysis Section at DMA if eligible for Medicaid coverage of pregnancy related services received during months of NC Health Choice eligibility. If ineligible for Medicaid, continue NC Health Choice coverage.

Incorrect Classification Code entered at approval

Yes

Change during the enrollment period unless it is 2 or fewer months prior to reenrollment. The change is effective the ongoing (EIS processing) month. Do not enter a change code on the 8125.

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