A. The DMA-5003/DMA-5003S, Approval Notice, replaces the manual DSS-8108/DSS-8108S, Notice of Benefits, for the Family and Children’s Medicaid categories. This form was developed by the following persons as a workgroup from the Economic Services Committee - Alvinia Parker, Elva Quinn, Joe Knott, Bill Horne, Helen Williams, Denise Knight, Paul Bruck, Betsy Jones, Brooke Grady, and Janet Bryan. There is a new separate manual approval notice for Aged, Blind and Disabled and it is the DMA-5002. The automated DSS-8108A/DSS-8108S, Notice of Benefits, remains the same.
C. Forms DSS-8109/DSS-8109S, Your Application for Benefits Is Being Denied or Withdrawn, and DSS-8110/DSS-8110S, Your Benefits Are Changing, have been renamed to reflect the name of the forms located on the DSS forms website.
D. Caseworkers must manually add the following sentence to the manual approval notices that do not contain information about Medicare Part D.: “If you receive Medicare, Medicare is responsible for your prescriptions.”
E. For Medicare recipients, caseworkers must manually add the following sentence to the manual adequate and timely notice that does not contain information about Medicare Part D.: “Now that you are enrolled/receiving Medicare, Medicaid will not pay your prescriptions. Medicare is responsible for your prescriptions.”
DATE: DECEMBER 19, 2005
Manual: Family and Children’s Medicaid
Change No: 02-06
To: County Directors of Social Services
Effective: January 1, 2006
When an application is approved or benefits are continued and you use a manual notice, send the DMA-5003/DMA-5003S, Approval Notice. You may also use the automated DSS-8108A/DSS-8108S, Notice of Benefits, for applications approved or benefits continued.
The DMA-5003/DMA-5003S, Approval Notice, will be on the DMA forms website. The Spanish version will be placed on the forms website once translation of the form into Spanish is complete. We will notify you by terminal message when the Spanish form is available.
The following sentence for Family Planning Services has been included on the DMA-5003/DMA-5003S, Approval Notice effective 1/1/06: “Your partner may be potentially eligible also.” For forms with effective date prior to 1/1/06, you must add the above sentence.
This policy is effective January 1, 2006. Apply this change to pending applications and redeterminations effective January 1, 2006.
If you have any questions, please contact your Medicaid Program Representative.
L. Allen Dobson, Jr., M.D., Assistant Secretary
for Health Policy and Medical Assistance
(This material was researched and written by Sandi Morrow, Policy Consultant, Medicaid Eligibility Unit.)
For questions or clarification on any of the policy contained in these manuals, please contact your local county office.