E. The requirement to send out two requests for information with 10 calendar days between requests changed to sending out two requests for information with 12 calendar days between requests. (The 10-10 rule became the 12-12 rule.)
A. This section contains procedures for processing an application and all possible outcomes. All applications for Family and Children’s Medicaid aid/program categories must be processed within 45 calendar days.
D. Under certain circumstances, days may be excluded from processing time when the county DSS is waiting for the following information and this is the only information needed to process the application:
DATE: AUGUST 12, 2002
Manual: Family and Children’s Medicaid MA-3215
Change No: 08-03
To: County Directors of Social Services
Effective: October 1, 2002
On February 5, 2002, Judge Graham C. Mullen, Chief Judge, U.S. District Court for the Western District of North Carolina, dismissed the Alexander Consent Order. The February 1992 version of the Consent Order required payment of penalties or remedial fines if the counties did not process applications according to federal regulations and State rules.
Judge Mullen approved a “Plan to Assure Timely and Quality Services to Applicants for Medicaid, otherwise known as the Exit Plan”. The Centers for Medicare and Medicaid Services and Legal Services had approved this Exit Plan. The State had worked with a group of county representatives in developing this plan.
The persons from the following counties who worked on this plan were:
Brenda Davis of Catawba County
Millie Brown and Elva Quinn of Duplin County
Dave Bradshaw and Dale Moorefield of Forsyth County
Betty Barnes of Johnston County
Jean Biggs and Vicki Lewis of Martin County
Sarah Bradshaw and Alvinia Parker of Sampson County
Although the Exit Plan does not change all that the counties wanted, it did result in the dismissal of the Consent Order. The Exit Plan reflects the commitment of both the State and the counties to continue to provide accurate benefits to our citizens in a timely manner. Each county in the State deserves recognition for its efforts. It is critical that counties continue to provide accurate benefits in a timely manner.
Work First (WF) applications are not under the Exit Plan. However, a Work First application is considered an application for Medicaid. If a person comes to the agency to ask for financial assistance, he must be given the opportunity to apply for Medicaid that same day. This applies even if the county requires the person to go to the Employment Security Commission or to the Child Support Enforcement office before taking a WF application.
Due to changes needed in the Eligibility Information System, all aspects of the Exit Plan could not be implemented until EIS was ready. In DMA Administrative Letter No. 19-02, some policy changes were made without EIS support. These included:
As a result of enhancement to EIS, all of the aspects of the Exit Plan can now be implemented.
MA-3215, Application Processing, Processing Situations, has been rewritten and renamed MA-3215, Processing The Application.
In these situations, the application must pend beyond the application due date to allow the applicant or third party the full 12 days to provide the missing information. If the verification is not provided, the application may be denied on the 13th day following the second request for information.
An application may be denied on the 45th day for failure to provide information unless:
If 12 days have not passed since the second request for information, hold the application pending for the full 12 days following the second request for information, even if it pends beyond the 45th day.
When an individual is found eligible for a portion of a certification period, authorize assistance open/shut for the period of time the individual was eligible.
When a medically needy applicant requests ongoing Medicaid, the six-month deductible must be met prior to authorization regardless of the number of months in the ongoing certification period unless there is a change in income or the individual dies.
In this situation, the IMC should fully explain to the individual the option of applying for retroactive assistance including the reserve and residence requirements during the retroactive period.
The individual also reports that he has enough medical bills to meet the original six-month deductible. The certification period is January through June. Medical bills indicate that the six-month deductible was met on March 9th. The individual moved to the other state on March 16th.
Approve the application open/shut for March 9th through March 31st. Do not recompute the deductible. The ongoing six-month deductible must be met even if the certification period is three months.
To determine if the application has pended the 45 days, subtract the number of days the original application pended from 45. The difference is the number of days the reopened application must pend to meet the 45 day requirement. Do not include any days the application was closed.
For example, a MAF application dated June 10th was improperly denied on June 25th. The original application pended a total of 15 days. On August 30th, an administrative DSS-8125 was entered to reopen the application. The reopened application must pend for at least 30 calendar days (September 29th) or until 13 calendar days after the second request for information, whichever is later.
To determine if the application has pended 6 months, subtract the number of days the original application pended from 180. The difference is the number of days the reopened application must pend to meet the 6 month requirement. Do not include any days the application was closed.
For example, a MAF application dated June 10th was improperly denied on June 25th. The original application pended a total of 15 days. On August 30th, an administrative DSS-8125 was entered to reopen the application. A review of the case record indicates that anticipated medical expenses are within $300.00 of meeting the deductible and this is the only information needed to complete the application. The reopened application must pend for at least 165 days (February 11th) or until 13 calendar days after the second request for information, whichever is later.
This policy change is effective October 1, 2002.
Apply these changes to any applications taken on or after October 1, 2002. For applications dated prior to October 1, 2002, follow the policies and procedures in effect prior to October 1st. This means that for an application taken prior to October 1, 2002, days can only be excluded from the application processing time while waiting for bills to meet the deductible.
Remove: MA-3215, Application Processing, Processing Situations.
Insert: MA-3215, Processing The Application.
Online Manual: Entire Section Revised with hyperlinks to forms.
Remove: MA-5000, Figures and Instructions for the following forms:
A. DSS-8109, Notice Of Denial Of Public Assistance.
B. DSS-8191W, Notice of Withdrawal.
Insert: Nothing to insert.
Online Manual: These forms have been added to the policy section.
If you have any questions regarding this material, please contact your Medicaid Program Representative.
(This policy was researched and written by Vanessa Broadhurst, Policy Consultant, Medicaid Eligibility Unit.)
MA-3215, Fig. 1, DSS-8109
For questions or clarification on any of the policy contained in these manuals, please contact your local county office.