A. The DMA-5063R, Health Check/Health Choice Re-enrollment application and the DMA-5063I, Information Sheet, have been revised and redesigned. The revised DMA-5063R and DMA-5063I, which is automatically computer generated and mailed from Raleigh, will be mailed to recipients effective 12/01/06.
DATE: NOVEMBER 22, 2006
Manual: Family and Children’s Medicaid
Change No: 20-06
To: County Directors of Social Services
The changes made the DMA-5063I reflect the following revisions:
• Defined Early, Periodic, Screening, Diagnosis, and Treatment (EPSDT) and provided EPSDT services information.
• Explanation of re-enrollment process and enrollment fees and co-pays.
The changes made to the DMA-5063R reflect the following revisions:
• The names of all the children being reviewed will be listed.
• Included instructions that Social Security Numbers are only required for applicants.
• Added policy holder name and relationship to Family’s Health Insurance required information.
• Changed child support reference of “child support” to “medical support”.
• Included Community Care of North Carolina/Carolina ACCESS (CCNC/CA) insert information. The DMA-5063ii, Carolina ACCESS insert is obsolete.
• Added an additional page to include;
Children with special health care needs questions, and
Request to apply for pregnancy coverage, family planning waiver services, and Medicaid for parent(s) or adult relatives listed on the application.
This policy is effective December 1, 2006. Begin applying this policy to redeterminations for MIC and NC Health Choice cases receiving automated re-enrollment forms for certification periods ending January 31, 2007, and forward. Begin applying this policy to redeterminations for MAF and MPW cases with certification periods ending January 31, 2007.
If you have forms that do not contain the children with special needs questions, etc., send the forms needed to meet requirements.
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 Charlotte Gibbons, Policy Consultant, Medicaid Eligibility Unit.
For questions or clarification on any of the policy contained in these manuals, please contact your local county office.