Family and Children's Medicaid MA-3255 NC HEALTH CHOICE
IV. EVALUATING NC HEALTH CHOICE ELIGIBILITY
A. Budgeting Procedures - Initial and Re-enrollment
1. Follow procedures as outlined in MA-3305, M-AF, M-IC, H-SF Budgeting, for evaluating Medicaid eligibility. Each child must be evaluated separately and determined ineligible for full Medicaid benefits under any category before considering coverage under NC Health Choice.
2. Unrelated children who do not have a parent in the home must be included in the NC Health Choice assistance unit (this is different than MIC).
3. Divide assistance units for budgeting purposes, as in MIC, when one child's income or a stepparent's income causes a child(ren) to be ineligible.
4. If a family includes MAF/MIC and NC Health Choice eligibles, include the MAF/MIC children in the NC Health Choice needs unit. This is necessary to ensure that the appropriate family income level is applied. Refer to MA-3305, M-AF, M-IC, H-SF, Budgeting, for instructions for establishing the needs unit
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1. Uninsured - To be eligible and authorized for NC Health Choice, the child must be uninsured. This means that he cannot be covered by comprehensive medical insurance.
Comprehensive medical insurance is coverage which provides basic medical care and hospitalization, whether group, private plan, HMO, or other managed care plan. It also includes Medicare, TRICARE (Insurance for Military, formerly known as Champus), insurance for government employees, state health benefit risk pools and other public health plans. It does not include policies which pay for specific illnesses or pay a daily amount while a person is hospitalized.
a. Accept the applicant's statement regarding children covered by insurance and whether insurance has been discontinued. If insurance is to be discontinued and child meets all other eligibility requirements, begin NCHC the 1st day of the following month. See 3.
b. Contact the Medicaid Eligibility Unit of the Division of Medical Assistance at (919) 855- 4000 if it is questionable as to whether a policy is comprehensive.
c. Court Order for Medical Support
An absent parent may be under court order to provide medical coverage or medical support through direct payment. Follow policy in B.2 below.
(1) Consider the child insured if the absent parent is providing coverage through a medical insurance policy. If the plan is located outside of the child's county of residence, refers to e, below.
(2) Consider the child uninsured if the absent parent is not providing coverage under a medical insurance policy even if he or she has been ordered to make direct payment for medical care.
d. School Accident Policies
School accident policies are not comprehensive insurance and do not prevent a child from being eligible for NC Health Choice. Enter the policy in EIS on a DMA-2041 Third Party Health & Accident Resources Information. The system will accept insurance information in this situation.
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e. Health Plans Located Outside of County of Residence
(1) A child covered by a full service Health Maintenance Organization (HMO) which does not have a network of medical providers in the county in which the child lives is considered uninsured for purposes of determining eligibility for NC Health Choice for Children.
(2) Children are sometimes covered by plans located in another county or state. This often happens when an absent parent provides coverage through a plan obtained through employment. Use the following steps to determine if the child is insured:
(a) Determine if the coverage is through a full-service HMO which is licensed in North Carolina and the county of residence. Contact the HMO to determine the coverage area and if a medical provider network exists in the county in which the child lives (the HMO may be licensed but not providing services in the county).
(b) The child is uninsured if the plan does not have a provider network in the child’s county of residence. Document this in the beneficiaries’ record.
f. A child may also be covered by:
(1) An indemnity plan. Many indemnity plans only pay a certain amount per day for hospital care. The child is only considered insured if the plan provides comprehensive coverage as defined above.
(2) A Preferred Provider Organization in which the insured is required to go to certain doctors for coverage to be provided. If the child can obtain medical care under the plan in the county in which he lives, he is considered insured.
2. Cooperation In Enforcing an Existing Court Order to Provide Health Insurance
Do not complete an automated child support referral in EIS for applications designated as NC Health Choice (See II.F.above). If a child has a parent living outside of the home, ask if the absent parent has been ordered by a court to provide health insurance, or if there is a separation agreement which specifies that the absent parent will provide health insurance. Always complete an ACTS inquiry to search for an existing case.
a. If the answer is NO, and there is not an existing case in ACTS, document the record. Never require an applicant to cooperate with Child Support Enforcement unless there is already an existing order or separation agreement requiring that the absent parent provide health insurance.
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b. If the answer is YES:
(1) If the applicant says the absent parent is complying with an existing court order or separation agreement refer to IV.B.1.c.above.
(2) If the applicant says that the absent parent has failed to comply with an existing court order or separation agreement to provide health insurance:
c. Verify cooperation as follows:
(1) Online verification into the ACTS system
The ACTS system contains information about court orders for support which are established in North Carolina by Child Support Enforcement.
It also contains information about new or modified orders which are not established by Child Support Enforcement.
(2) Verify through the ACTS system whether there is an existing order. Consider the custodial parent to be in compliance with requirements to cooperate if the order appears in the ACTS system.
(a) To verify if an order exists in the ACTS system, use the Social Security number of the applicant/beneficiary. If the a/b has ever been assigned an ID number and is part of the Common Name Database, (CNDB) you can access information on him by entering other identifying information such as his first and last names.
(b) Refer to EIS 1109 for instructions on how to access the Online Verification system.
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(3) Information Unavailable Through ACTS
If the existing court order does not appear in the ACTS system, or if there is a separation agreement specifying that the absent parent provide health insurance, require the custodial parent to apply for services with Child Support Enforcement.
(a) Inform the custodial parent that he or she will be required to pay an application fee of $25.00. The custodial parent must provide the receipt showing payment of the application fee as proof of agreement to cooperate with the order.
(b) Deny the NC Health Choice application on the 45th day of the processing period if the custodial parent fails to provide proof of agreement to cooperate. Use denial code "A2."
(c) If the custodial parent cannot obtain an appointment within the 45 day processing period, he or she must bring a statement from the child support office indicating that an appointment has been scheduled.
1) Accept this as tentative proof of cooperation and approve the application if all other eligibility factors are met.
2) Flag the case for follow-up during the week after the scheduled appointment and notify the custodial parent to bring in the receipt within 12 calendar days.
3) If he or she fails to provide the receipt, send timely notice to propose termination of the case.
4) Use code 23 (There is no longer an eligible child in the home) to terminate the case if the receipt is not provided during the timely notice period.
3. Procedures to Follow When Insurance is Voluntarily Discontinued
Comprehensive medical insurance coverage for a child must be discontinued before NC Health Choice can be authorized. As soon as it is known that a child has comprehensive medical insurance coverage, notify the a/b that verification of terminated insurance must be provided by the application due date. When a freeze on new enrollment occurs, a family should not discontinue insurance until the case is reactivated.
a. Send a DMA-5097 (DMA-5097, Spanish) requesting verification of discontinued insurance coverage. Explain to the a/b that insurance coverage must end by the last day of the month in which the 45th day falls. In addition, explain to the a/b that if the insurance does not terminate on the last day of the month, the child may be without coverage as NC Health Choice cannot begin until the 1st of the next month.
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b. Send a second DMA-5097 (DMA-5097, Spanish) if verification of discontinued insurance is not provided within 12 calendar days.
c. Verify discontinued insurance coverage by verbal or written contact with the a/b or the insurance company. If verification of discontinued insurance is provided by the 45th day, authorize NC Health Choice effective the 1st of the month after the insurance coverage ends but no later than the month following the month of the 45th day. The Certification From Date and the Medicaid Effective Date must be the same. The Claims Unit charges 100% to county funds when county has incorrectly authorized person for Medicaid and EIS shows authorization for NCHC if a provider demands Medicaid payment based on issuance of Medicaid Identification card.
d. Evaluate for MAF-M if insurance coverage ends prior to the last day of the month and the a/b indicates there are medical bills to meet a deductible.
e. If verification of discontinued insurance is not provided by the 45th day, deny the application, provided 2 requests with 12 calendar days in between have been sent.
C. Classification for Health Choice
1. Classification Code “J”
Use this code for NC Health Choice cases that have income at or below 159% of the poverty level. While these families do not pay an enrollment fee, they are responsible for cost sharing.
2. Classification Code “K”
Use this code for NC Health Choice cases that have income which exceeds 159% of the federal poverty level. These families pay an enrollment fee and cost sharing.
3. Classification Code “A”
Use this code for NC Health Choice cases that are members of a federally recognized Indian tribe or Alaskan Native whose income is equal to or less than 159% of the federal poverty level. These families have no enrollment fee or cost sharing
4. Classification Code “S”
Use this code for NC Health Choice cases that are members of a federally recognized Indian tribe or Alaskan Native whose income exceeds 159% of the federal poverty level. These families have no enrollment fee or cost sharing.
5. Classification Code "L"
Use this code to designate a child(ren) whose family income at the NC Health Choice re-enrollment is greater than 211% but equal or less than 225% of the federal poverty level (including members of a federally recognized Indian tribe). The family has the option of “buying-in" to coverage by paying the premium for a period not to exceed one year. If erroneous classification code is entered, see VI.D below.
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D. Enrollment Fee
Families with countable income over 159% of the federal poverty level must pay an enrollment fee of $50.00 per child eligible for NC Health Choice, not to exceed $100.00 per family. This does not apply to federally recognized Indian tribes or Alaskan Natives. Refer to the chart in II. A. 3. above to determine if an enrollment fee is due. When a freeze on new enrollment occurs, a family does not pay the fee until the case is reactivated.
1. Determine if an Enrollment Fee is Due
a. Calculate the amount of total countable net income for the individuals in the needs unit(s). If children have been budgeted separately use the income for the total number of people in the needs unit(s) which will be entered in EIS (not to exceed 211% of the poverty level) and reported to the claims processing system. See IV.A. above.
b. Compare this amount to the chart in II. A. 3. above. If total countable income exceeds the 159% amount for the number in the needs unit, an enrollment fee is due.
2. Notification of Enrollment Fee
Upon determination that an applicant(s) is eligible for NC Health Choice and the family income exceeds 159% of the federal poverty level, send a DMA-5059, North Carolina Health Choice – Enrollment Fee Notice, to notify the applicant.
a. Give the parent/caretaker at least 12 calendar days to pay the fee.
b. If 12 calendar days exceeds the 45 day processing standard, pend until you receive notice of payment, or, until the first workday after the due date for payment.
Allow for the exclusion of days when income verification is received and the application must pend beyond 45 days in order to notify the applicant and receive the North Carolina Health Choice (NCHC) fee. The exclusion of days will begin on the day of the request for the fee and end on the day the fee is received or on the 13th calendar day, whichever occurs first. Use FEE code for this purpose. Refer to MA-3215, Processing the Application.
c. Inform the office or individual responsible for collecting the fee of the date by which the fee must be paid and by when the IMC must be informed of payment or non-payment.
a. Each county is responsible for establishing procedures for collection of enrollment fees.
(1) Determine which methods of payment (i.e. cash, check, money order) are acceptable. If the county chooses to accept personal checks, they cannot terminate the NCHC case if the check does not clear the bank.
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(2) Partial payment is not allowed. The entire fee must be paid prior to approval of the application.
b. Determine what office and/or person(s) are responsible for collection of enrollment fees for NC Health Choice. This decision must be communicated in writing to all staff who are determining eligibility for NC Health Choice.
c. Establish procedures for communication between the IMC staff and the fee collector for:
(1) Identification of case/individuals who must pay an enrollment fee, and
(2) The amount of the fee due, and
(3) The date by which the fee must be paid, and
(4) The time frame and method for notification to the IMC that the fee has been paid, or
(5) Notification that the parent/caretaker refused to pay, or failed to pay the fee by the date due.
d. The enrollment fee may be paid with funds provided by individuals or organizations other than the applicant, including county funds. The total of enrollment fees due offset the county's reimbursement for administrative purposes.
4. Decision Following Payment or Non-Payment
a. Upon receipt of notification from the fee collector that the enrollment fee has been paid, authorize eligibility according to instructions in V. below.
b. Upon receipt of notification from the fee collector that the parent/caretaker refused to pay the fee, or failed to pay the fee, deny the application according to instructions in V. below.
c. If no communication has been received from the fee collector on the first workday following the date on which the fee was due, contact the collection agency/person to verify status. If payment has not been made, document the contact and deny the application according to instructions in V. below.