Family and Children's Medicaid MA-3205 CONDUCTING A FACE-TO-FACE INTAKE INTERVIEW
Iv. Rights and responsibilities
Each individual or his representative must be informed, in writing or orally, of his rights and responsibilities. Document how the information was furnished. A representative has the same rights and responsibilities as the individual.
Review with and explain to the individual the rights listed on the base document, the DMA-5094/DMA-5094S, Notice of Your Right to Apply for Benefits, and the DSS-8227/DSS-8227S, Immigrant Access Notice. In addition, explain the following:
1. The 45-day application processing standard.
2. He must cooperate in providing information needed to establish eligibility and if a U.S. citizen, information to prove U.S. citizenship and identity.
3. He will be notified of any information he is to provide.
a. He is to receive a written notice, DMA-5097/DMA-5097S, Request for Information, on the day of the application listing any information he is to provide.
b. Another DMA-5097/DMA-5097S, Request for Information, must be sent if additional information is needed, as soon as the need becomes known.
c. He will receive a second DMA-5097/DMA-5097S, Request for Information, if information he was to provide is not received.
d. He may request help from the agency in getting the needed information.
4. His application may be held up to six months for proof that he can meet a Medicaid deductible or for his disability to be determined provided he meets all other eligibility factors.
5. He may request help for retroactive coverage up to three calendar months prior to the month of application.
6. He does not have to have a permanent address. The only requirement is that he intends to stay in North Carolina.
Please note: Refer to MA-3335, State Residence, for state residency verification instructions for individuals, including the homeless, who do not have a permanent address.
a. Request any information from him on the date of application using the DMA-5097/DMA-5097S, Request for Information.
REVISED 12/01/10 – CHANGE NO. 16-10
b. Ask the individual if he has an address where he can get mail. If he does, inform him to check his mailing address for requests for additional information, notices and his Medicaid identification card.
If he does not:
(1) Inform him that he must return or contact the agency to see if any additional information is needed. Negotiate a date for the contact but allow at least 12 days from the first request. Document the date on the DMA-5097/DMA-5097S. Request for Information.
(2) If the application is approved, inform the individual that he must come to the agency to obtain his Medicaid identification card and any other notices.
7. He may apply for a deceased individual.
8. He has the right to appeal the decisions of the agency.
Review with and explain to the individual the responsibilities listed on the base document, the DMA-5094/DMA-5094S, Notice of Your Right to Apply for Benefits, and the DSS-8227/DSS-8227S, Immigrant Access Notice. In addition, explain the following:
1. He must cooperate in providing information needed to establish eligibility and, if a U. S. citizen, information to prove U.S. citizenship and identity. NC Health Choice also requires proof of U.S, citizenship and identity. See MA-3332, U.S. Citizenship Requirements.
2. Members of the assistance unit must apply for all benefits to which they might be entitled, such as Social Security and VA benefits. This does not apply to budget unit members.
3. Members of the assistance unit must provide a social security number or apply for a number. This does not apply to budget unit members when applying for emergency Medicaid for aliens. Refer to MA-3355, Enumeration Procedures.
REVISED 12/01/10 – CHANGE NO. 16-10