Unlike Medicaid, NCHC benefits are provided through the State Employees Health Plan (SEHP).
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NOTE: There is no recipient profile to request since the monthly fee encompasses all services received in a month.
Example: Ms. Pickles applied for NCHC for her three children on 10/01/08. She stated she received her support payments by a money order in an envelope with no return address, and provided a copy of the most recent money order. She also stated there was no Third Party Insurance coverage on the children. Her reported income was too high for MIC-N
The worker verified thru ACTS that there was no Medical Support order in place at that time. The worker reminded the client she was required to report all insurance coverage for the children within 10 days of her knowledge of the change. She also reminded her that the children would not be eligible for NCHC once coverage by a third party became available.
At her annual review on 08/22/09, Ms. Pickles reported her children’s father provided Prudential medical cards for her children on 12/24/08. When asked why she never reported it, she stated that she never used it since she had NCHC on the children. She also stated that the copayments for the insurance provided by the AP were more than that of NCHC. A DSS- 8110 (Timely Notice) was completed and mailed to the client on 08/22/09 to terminate the NCHC case effective 09/30/09.
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Determine ineligibility and calculate the overpayment as follows:
Step 1: Verify the insurance is major medical. A telephone call to the insurance carrier verified each child had major medical coverage effective 12/01/08.
Step 2: Determine the period of ineligibility.
The NCHC date of application is 10/01/08. The client received the medical cards on 12/24/08. Allow 10 calendar days for the client to report the change (1/3/09). Also allow 10 working days for the timely notice to terminate the NCHC case as if the information had been reported timely (1/19/10). The case would have terminated 01/31/09. The period of ineligibility is 02/01/09 through 09/30/09, 8 months. The NCHC premium paid by SEHP for each child during the period of ineligibility was $146.84 per month.
Step 3: Determine the overpayment.
$146.84 x 8 months = $1,174.72 per child
$1,174.72 x 3 children = $3,524.16
Since the period of ineligibility did not include any months on or after July 1, 2010, the total NCHC overpayment is $3,524.16. Enter this amount in EPICS with the service code 67 for NCHC.
Effective July 1, 2010, the Division of Medical Assistance eliminated the premium payments for NCHC. Overpayments for NCHC will be based on the amount of claims paid during the period of ineligibility.
NOTE: Do not combine requests for NCHC and Medicaid claims on the same DMA-7063.
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the two periods together to get the total NCHC overpayment.
01/02/09: Ima Lyon applies for Medicaid for her 8 year old grandson, Tommy Thumb. She states her son, Thom Thumb, left his son in her care when he took an out of state assignment. She states the only income Tommy has is from Social Security (due to his mother being deceased) in the amount of $1,015/month. She states she receives no child support.
01/20/09: Tommy Thumb approved for NCHC from 1/09-12/09.
11/30/09: Ima Lyon completed the review stating there was no change. Tommy is again approved for NCHC for 1/10-12/10
11/15/10: DMA Program Integrity received a call from Pretty Madd, ex-girlfriend of Thom Thumb. She stated she just learned his son was getting Medicaid. She stated she wanted to know how this could be since his father is in the home and working. She reported that he works for “On the Move Movers”, making $2,400/month. She knows this is true because she does the books for On the Move Movers. Additionally, he has Tommy on his health insurance. She states Thom went to live with his mother Ima Lyon and Tommy on November 25, 2009 when she kicked him out. She faxed DMA proof of the insurance and his pay. A referral was sent to the local DSS PI office.
11/19/10: An investigation was conducted and it was determined that Thom Thumb was in the home and had been at the time of Ms. Lyons’ last review. The verification obtained reflected that Mr. Thumb’s salary with “On the Move Movers” was $2,400/month since he was employed as of 10/17/09. It also showed he paid for insurance for him and Tommy. The coverage with BCBS began with 01/01/10. It was also determined that Mr. Thumb provided Ima Lyon with the insurance card and was unaware that she was receiving NC Health Choice for his son. A written summary of findings were sent to the caseworker.
12/01/10: The case worker sent a DSS 8110 to Ms. Lyon to terminate Tommy Thumb’s NCHC terminated effective 12/31/10. A referral was sent to PI.
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Tommy was eligible for NCHC from 1/09-12/09.
His father, Thom Thumb moved in with him and Ima Lyon on 11/25/2009. Ms. Lyon should have reported the change in household composition at review on 11/30/09. When Thom’s income is added together with Tommy’s SSA income, Tommy is ineligible for NCHC effective with January 2010.
The period of ineligible is from 1/10-12/10.
The overpayment for 1/2010-6/2010 is based on the premium paid by the State.
159.73 x 6 = $958.38
The overpayment for 7/2010-12/2010 is based on the actual services used. To determine this amount, a profile (DMA-7063) must be sent to DMA.
The profile is ordered and it shows that $4,596.35 in services was used during 7/2010-12/2010.
The total overpayment includes premiums (1/10-6/10) and actual NCHC claims paid (7/10-12/10). Add together the amounts of the two periods together to get the total NCHC overpayment.
$ 958.38 + $4,596.35= $5,554.73
For questions or clarification on any of the policy contained in these manuals, please contact your local county office.