Family and Children's Medicaid MA-3255 NC HEALTH CHOICE

III. APPLICATION PROCEDURES

The application is considered to be an application for medical coverage. Evaluate eligibility for full Medicaid benefits and if ineligible, consider coverage under NC Health Choice.

A. Availability of Application

1. An application may be made at the Department of Social Services, or

2. An individual may pick up an application or request an application by telephone or mail. The application may then be completed and mailed in.

3. Applications are also available at Health Departments and other local entities as determined by the local coalition formed by the DSS and Health Department directors

B. Who May Apply

1. A parent/caretaker or a representative acting on behalf of the parent/caretaker may apply for NC Health Choice coverage for children in the home.

2. An absent parent may apply as representative for children that are no longer in their custody. However, the child’s eligibility is solely based upon the financially responsible person with whom the child lives.

3. A child under 19 who lives independently of parental care may apply for coverage for himself (including married and under age 19).

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(III.)

C. The Application Form

An application has been created to use as a joint application for Medicaid/NC Health Choice. Supplements are provided to evaluate for MAF eligibility. This application and supplements replace the previous Family and Children's Medicaid Application and consist of the following:

1. DMA-5063(DMA-5063, Spanish) - Medicaid/NC Health Choice Application - A detachable application form which may be completed by the IMC, the applicant, or entities trained by the DSS for this purpose. Included with the form is a cover letter explaining Medicaid and NCHC, instructions for self-completion, a notice of Rights and Responsibilities and available services. The form also serves as consent for release of information.

2. DMA-5064 - MIC/NC Health Choice Budget Worksheet, Supplement 1. This form is to be used by the IMC only in determining eligibility for assistance.

3. DMA-5065 - MAF Application/Budgeting Worksheet, Supplement 2. This form is to be used for caretakers/parents; children age 19 and 20, and children ineligible for MIC and NC Health Choice.

4. Use the following forms to supplement the DMA-5063 (DMA-5063, Spanish), Medicaid/NC Health Choice Application. DMA continues to stock and supply these forms.

a. DMA-5043 – Verification Form for Self-Employment Income and Expenses.

b. DMA-5063BB – Verification of Change in Situation.

D. Obtaining an Application Form from the DSS

1. Anyone who appears in the agency requesting medical or financial assistance must be logged. This includes individuals who request a mail-in application form from the receptionist. Individuals picking up a mail-in application form without speaking with the receptionist do not have to be logged.

a. Explain to the individual his right to apply for assistance and have him sign, as appropriate, the DMA-5094 or DMA-5094S, Notice of Your Right to Apply for Benefits.

b. Either the reception staff or the caseworker can provide this explanation and the DMA-5094 or DMA-5094S, Notice of Your Right to Apply for Benefits. However, because the form provides instructions regarding the application process, it is strongly suggested that the reception staff complete this task.

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(III.D.1.)

c. Give the individual the original DMA-5094 or DMA-5094S, Notice of Your Right to Apply for Benefits, and file a copy with the log.

2. Give the individual the DSS-8227, Immigrant Access Notice. Either the reception staff or the caseworker can provide this information. However, because the form provides information regarding the application process, it is strongly suggested that the reception staff complete this task. Document on the bottom of the DMA-5094 or DMA-5094S, Notice of Your Right to Apply for Benefits, that the DSS-8227/DSS-8227S, Immigrant Access Notice, form was given to the individual.

E. Applications Taken at the DSS

1. Intake procedures are not changed for in-house applications. Treat all applications as if the applicant is applying for Medicaid.

2. If the applicant specifies that he or she only wants to apply for coverage through NC Health Choice explain that the application must be evaluated for Medicaid.

3. The applicant may withdraw the application if he does not wish to have coverage for children who are eligible for Medicaid.

a. Log Procedures

Follow procedures in MA-3200, Initial Contact, to log requests for assistance.

b. Inquiries

Complete the DMA-5095 (DMA-5095S), Medicaid/Work First Notice of Inquiry only if no application is taken for any program.

c. Follow procedures in MA-3205, Conducting A Face-to-Face Intake Interview.

d. Other Services

Explain services available to the applicant. Advise the applicant that, if approved for NC Health Choice, DMA will provide information about covered services and how to obtain them.

F. Processing the Application

All applications are processed as Medicaid until income verification establishes ineligibility for Medicaid, and eligibility or ineligibility for NC Health Choice.

1. Enter the application in EIS as MIC. Do not complete the NC Health Choice indicator unless income has been verified and establishes ineligibility for Medicaid.

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(III.F.)

2. If the applicant chooses to be interviewed by an IMC, follow procedures in E.

3. Follow all requirements in MA-3210, Verification Requirements for Applications, and MA-3215, Processing the Application, for requesting information, pending periods, etc.

NOTE: NC Health Choice is excluded from monitoring and the report card. However, applications in which individuals are approved for Medicaid remain subject to monitoring and the report card requirements. Refer to MA-3217, Evaluating County/DDS Performance.

4. NC Health Choice Applications and the Eligibility Information System (EIS)

a. Source Field Indicator

Mail In DSS Health Dept. DATE RECEIVED / /

The application contains a source field (see example above) for specifying whether an application was completed by the county dss, provided by or assisted by the health department or was a mail-in application. State law requires that source of application be tracked. This information must be entered in the "How App Received" field on the 8124 screen prior to disposition of the application.

b. The source of the application is important for tracking purposes and may differ from the way the application is treated for processing. For tracking purposes:

(1) Mail-in

A "mail-in" is any application (other than one obtained from the health department) which is mailed or brought to the dss by the applicant without being interviewed by an IMC. Enter code "M" in EIS.

(2) DSS

A dss application is any application in which a face to face interview is conducted in any location by an IMC. The DSS should supply the DMA-5063 (DMA-5063, Spanish), Medicaid/NC Health Choice Application, to its staff at any outstation locations where interviews are conducted. Enter code "D" in EIS.

(3) Health Department

A health department application is an application which is distributed and stamped by the health department, and is mailed or brought in to the dss without a face to face interview being conducted by an IMC. Enter code "H" in EIS.

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G. MAF Eligibility

Evaluate for MAF when the applicant requests coverage for an individual who does not meet MIC/NC Health Choice eligibility requirements.

1. The DMA-5065 (MAF Supplement) may be completed by telephone contact with the applicant. A signature is not required. Document that the information was received by telephone.

2. If the applicant cannot be contacted by phone, send the DMA-5097 (DMA-5097, Spanish) requesting that the applicant contact the agency to complete the MAF application.

3. Follow procedures in MA-3210, Verification Requirements for Applications, and MA-3215, Processing the Application, for requesting information and processing the application. The dss is not required to contact the applicant about medical bills to meet an ongoing or retroactive deductible unless the mail-in application indicates a medical need.

H. Evaluate Medicaid for Retroactive Period

Evaluate for retroactive Medicaid when the applicant indicates there are medical expenses in any of the three months prior to application. Enter a separate application in EIS for the retroactive period. This application is subject to monitoring and the report card.