Adult Medicaid Manual MA-2301 CONDUCTING A FACE-TO-FACE INTAKE INTERVIEW

III. INFORMATION REGARDING THE MEDICAID PROGRAM

A. Medicaid Coverage Groups

Explain to the individual that the Medicaid program covers groups of people based on certain categorical requirements.

1. Medicaid for the Aged, Blind, and Disabled, including Health Coverage for Workers with Disabilities (HCWD).

Refer to MA-2000, Non-SSI Eligibility Regulations, in the Aged, Blind, and Disabled Medicaid Manual and to MA-2180, Health Coverage for Workers with Disabilities.

This program provides full coverage for eligible individuals who are:

a. Age 65 or older, or

b. Blind as defined by the Social Security Administration or a recipient of State Aid for the Blind, or

The Social Security Administration defines blindness as a central visual acuity of 20/200 or less in the better eye, with the use of a correcting lens or a limitation in the field of vision of the better eye that meets specific criteria.

c. Disabled as defined by the Social Security Administration.

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(III.A.1.c.)

(1) The Social Security Administration defines disability as a physical or mental impairment, which prevents an individual from engaging in any substantial gainful activity (or for a child under 18, an impairment of comparable severity), and which has lasted or is expected to last for at least 12 months or result in death. For HCWD individuals substantial gainful activity is not a consideration.

(2) If the individual is not already receiving Social Security benefits based on disability, the Disability Determination Services (DDS) will determine if the individual meets the criteria for disability. Refer to MA-2525, Disability. If an HCWD a/r has had his disability terminated within the last 12 months, a new disability determination may not be necessary. See MA-2180, Health Coverage for Workers with Disabilities.

2. Medicare Savings Programs (MQB)

Refer to MA-2130, Qualified Medicare Beneficiaries-Q, MA-2140, Qualified Medicare Beneficiaries-B, and MA-2160, Qualifying Individuals-1, (MQB-E), in the Aged, Blind, and Disabled Medicaid Manual.

These programs provide limited coverage of services for eligible individuals who are entitled to Medicare.

3. Medicaid for the Working Disabled

Refer to MA-2150, Medicaid-Working Disabled, in the Aged, Blind, and Disabled Medicaid Manual.

This program provides limited coverage of services for qualified disabled working individuals who have lost entitlement to premium free Medicare Part A solely due to earnings as determined by the Social Security Administration.

4. Medicaid for Families and Children

Refer to MA-3230, Eligibility of Individuals Under 21, MA-3235, Caretaker Relative Eligibility, MA-3240, Pregnant Woman Coverage, MA-3250, Breast and Cervical Cancer Medicaid, and MA-3265, Medicaid Family Planning Waiver, in the Family and Children’s Medicaid Manual.

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(III.A.4.)

These programs provide coverage to eligible children under age 21, caretaker relatives of children under age 19, pregnant women, and women enrolled, screened, and diagnosed with breast or cervical cancer including pre-cancerous conditions and early stage cancer and limited family planning coverage to women ages 19 through 55 and men ages 19 through 60.

Coverage also includes the Expanded Foster Care Program (EFCP) for IAS and HSF adolescents ages 18, 19, and 20 without regard to the adolescent’s assets or income levels through the month they turn age 21.

5. North Carolina Health Choice for Children

Refer to MA-3255, NC Health Choice, in the Family and Children’s Medicaid Manual.

This program provides health insurance for children age 6 through age 18 who are ineligible for Medicaid and have family income less than 200% of the federal poverty level. Children are evaluated for and enrolled in NC Health Choice only after they are determined ineligible for Medicaid.

B. Eligibility Requirements

Explain to the individual that, in addition to meeting the criteria for a Medicaid coverage group, he must also meet the other eligibility requirements including income and, in some cases, resource requirements. Additionally, the individual must provide and/or cooperate in obtaining proof of citizenship, identity, and state residence. The DMA-5096 is a tool for documenting the applicant’s responses to basic eligibility requirements and for evaluating eligibility under all possible Medicaid coverage groups.

C. Retroactive and Ongoing Medicaid

Refer to MA-2370, Retroactive Coverage.

1. Explain to the individual that Medicaid may be used to pay bills incurred in the three months prior to the month of application, if he is otherwise eligible.

a. You must ask the individual if he has any medical bills in the retroactive months. You must also document his response.

b. If the individual’s income results in a deductible, explain the advantages and disadvantages of applying for Medicaid retroactively as opposed to ongoing. Include a detailed explanation of the reserve and residence requirements during the retroactive period.

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(III.C.)

2. Explain that ongoing coverage begins the first day of the month of application if all eligibility requirements are met. Discuss the reserve requirements, including burial exclusion, rebuttal and reduction and explain that Medicaid cannot be authorized until the reserve requirements are met.

D. Transfer of Resources

Refer to MA-2240, Transfer of Assets, MA-2242, Home Equity Value & Eligibility For Institutional Services, and MA-2245, Undue Hardship Waiver For Transfer Of Assets.

1. Interview the individual and the individual’s spouse or his legal representative regarding income and resources for a period of 36 months up to 60 months to determine if a transfer (s) occurred and document the response in the case record.

2. Explain to the individual that a transfer of assets sanction may be imposed if any asset or income is transferred without receiving compensation equal to the current market value of the asset or income.

3. Explain that an individual under a transfer of assets sanction may not be eligible for assistance with nursing home cost of care, Community Alternatives Program (CAP) services, Program of All-Inclusive Care for the Elderly (PACE) services, or receive in-home health services and supplies after the individual has been sanctioned for institutionalized services.

Give the individual the DMA-5057/DMA-5057S, Explanation of The Effect of Transfer of Asset (s) On Medical Assistance Eligibility. For further explanation refer to MA-2240, Transfer of Assets.

4. Explain that if the equity value of the homesite is over $500,000, and there is not a spouse, disabled, blind or minor child living in the home, the applicant/recipient is ineligible for nursing home cost of care, or CAP waiver programs, or Program of All-Inclusive Care for the Elderly (PACE). The individual may still be eligible for PLA. Refer to MA-2242, Home Equity Value & Eligibility For Institutional Services.

5. Explain that if an annuity is purchased or changed on or after November 1, 2007, by the a/r or by the a/r’s spouse, or by their legal representative the State of North Carolina Medicaid Program must be named as a remainder beneficiary.

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(III.D.)

6. Excluding Program of All-Inclusive Care for the Elderly (PACE), that an individual under a transfer of assets sanction may be eligible for other Medicaid covered services. PACE applicants/recipients are only eligible for the MQB program/category. Refer to MA-2275, Program of All-Inclusive Care for the Elderly (PACE).

7. Always document the applicant’s responses regarding transfer of assets in the case file.

E. Deductible

Refer to MA-2360, Medicaid Deductible.

1. Based on the client’s statement of income, compute an estimated deductible, if applicable, for both the retroactive and ongoing periods.

2. Explain the deductible to the individual. Include the following information.

a. Medical bills equal to or exceeding the deductible amount must be incurred before Medicaid can be authorized.

b. The individual is responsible for the deductible amount.

c. Explain to the individual whose expenses and what expenses can be used to meet the Medicaid deductible. You must ask the individual the following questions and document his response in the record:

(1) What regular medical expenses does the budget unit have on a monthly basis? (current expenses)

(2) Does anyone in the budget unit have any unpaid medical expenses for which he is still responsible? (old bills)

(3) Does anyone in the budget unit anticipate any new medical expenses, such as a scheduled hospital stay? (anticipated expenses)

3. If, based on the individual’s statement, it appears that he is or will be within $300.00 of meeting the deductible, explain to the individual that, if all other factors of eligibility have been met, his application may be held for up to six months. See MA-2304, Processing the Application, for procedures.

F. MAD Applications Requiring a Disability Determination (Including HCWD)

Refer to MA-2525, Disability

1. Explain to the individual that Disability Determination Services (DDS) will determine if his medical condition meets the definition of disability.

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(III.F)

2. Advise the individual that DDS may contact him by phone or letter for additional information or to schedule a consultative examination.

a. If he fails to provide the information or keep the appointment, his application will be denied.

b. If he has questions or needs transportation, he may contact the IMC for assistance.

3. Explain to the individual that pregnancy alone is not considered a disabling condition and the pregnant woman will also be evaluated under the M-PW and M-AF programs.

4. If a Medicaid application has been denied for the individual in the last 60 days because DDS determined that his medical condition did not meet the definition of disability, explain the following:

a. He may appeal the denial with the Social Security Administration or the State, or make a new application, or both.

b. The advantage of requesting an appeal of the denial is that the date of the original application is protected. This is particularly important if the individual had a retroactive need at the time of the original application.

c. Document the individual’s decision in the record.

d. If the individual requests an appeal, follow policy in MA-2420, Notice and Hearings.

G. Choice of Programs

1. Explain the program options, including the advantages and disadvantages, for each program for which each individual is potentially eligible. If an individual is potentially eligible in two different programs, explain that he may apply for both.

2. An individual may choose to apply for MAABD and MQB or either MAABD or MQB. Unless the individual specifically chooses to apply for MAABD or MQB, always take and process the application for both.

3. Some examples of situations when eligibility may exist in more than one aid program/category are:

a. A pregnant woman may be eligible as M-AF, M-PW or, depending on her age, as M-IC

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(III.G.3.)

b. A disabled parent with children under age 19 may be eligible as M-AD or M-AF, including Family Planning Waiver.

c. A disabled individual under age 21 may be eligible as M-AD, M-AF, or M-IC.

For example, Renee is a 19-year-old who was living with her parents. She was in an accident two weeks ago and has a severe head injury. She has been hospitalized since the accident and the full extent of her injuries is still unknown.

Renee may qualify under Medicaid for the Disabled (M-AD), if her injury is severe enough to meet disability requirements, or Family and Children’s Medicaid, as an individual under 21. The IMC must explain the program requirements for each program and the advantages and disadvantages of the programs so the parents can decide which program to apply for or if they should file two separate applications. The issues to be explained include:

(1) Parental Financial Responsibility

(a) Under the M-AF program, the income and resources of the parents must be used to determine her eligibility unless the doctor states she will be out of the home for more than twelve months.

Explain the Medicaid deductible and how it can be met. Also explain the resource limits and that if resources exceed the limit, the individual is ineligible until the resources are reduced.

(b) Under the M-AD program, the income and resources of the parents do not apply to a child age 18 or older.

(2) Disability

To receive under the M-AD category, DDS must determine if Renee’s medical condition is severe enough to meet the disability criteria. Disability is not a requirement to receive under the M-AF program.

Based on the information provided, Renee’s parents may choose to apply for M-AF, M-AD, or ask that Renee be evaluated for both. Renee may be approved with an M-AF deductible while her disability is being determined under M-AD. If her condition meets the criteria for disability, M-AD can then be approved back to the date of the application, if otherwise eligible.

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(III.)

H. Certification Periods

Refer to MA-2350, Certification and Authorization.

1. Explain to the individual that eligibility is determined for a limited time, which is called the certification period.

2. Explain that the program in which the individual is found eligible determines the length of the certification period.

I. Long Term Care Placement (LTC)/Community Alternatives Programs (CAP)/Program of All-Inclusive Care for the Elderly (PACE)

An application may be taken for an individual who plans to enter or is in a nursing facility, an intermediate care facility for the mentally retarded (ICF-MR), a medical institution for medical, surgical or inpatient psychiatric care or a Psychiatric Residential Treatment Facility when the stay is expected to exceed 30 days or ends with a direct move into a nursing or ICF-MR facility, or who is in need of home and community based services under a CAP waiver program or the PACE program.

When long-term care, CAP or PACE assistance is requested, the IMC must explain the following:

1. The concept of long term care and PACE budgeting and the patient monthly liability (pml), or the concept of private living budgeting and the CAP monthly deductible. See MA-2270, Long Term Care Budgeting, and MA-2280, Community Alternatives Programs Medicaid Eligibility, MA-2275, Program of All-Inclusive Care for the Elderly (PACE).

2. The protection of assets and/or income for a spouse or dependent family member. See MA-2270, Long Term Care Budgeting, MA-2275, Program of All-Inclusive Care for the Elderly (PACE), and MA-2231, Community Spouse Resource Protection.

3. The need for a Prior Approval/Continued Care Review form (FL-2/MR-2), if required by policy. Include in the explanation that the Pre-Admission Screen and Annual Resident Review (PASARR) must be completed prior to approval of the FL2/MR2. Note: PASARR is not applicable for PACE applicants/recipients. Also explain that if there is a change in the required level of care, a new FL2/MR2 is required. See MA-2270, Long Term Care Budgeting and MA-2275, Program of All-Inclusive Care for the Elderly (PACE).

a. Inform the LTC and PACE applicant that if an FL-2/MR-2 is required, the individual must be placed within 30 days of the date of the telephone or stamped approval of the recommended level of care.

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(III.I.3.)

b. Inform the CAP applicant that an annual assessment (Plan of Care) is required to determine the continued need for CAP services.

4. The importance of notifying the DSS of any changes in the living arrangement or level of care.

5. Explain Estate Recovery rules. See DMA Administrative Letter No. 23-96 and Addenda and DMA Administrative Letter 09-05.

6. Explain transfer of asset regulations. Refer to MA-2240, Transfer of Assets, MA-2242, Home Equity Value & Eligibility For Institutional Services, and MA-2245, Undue Hardship Waiver For Transfer Of Assets.

J. Pre-Need Applications

There are only two types of pre-need applications under the Aged, Blind, and Disabled Medicaid program. An application for ongoing assistance may be taken for an individual who:

1. Is not a resident of North Carolina if the individual expects to meet the state residence requirements within the 45/90 day application processing period, or

2. Has not reached age 65 if the individual expects to meet the age requirements for the MAA program within the 45-day application processing period.

a. Explain to the applicant or his representative that the state residence and/or age requirement must be met by the 45th/90th day. If the requirement(s) is not met by the 45th/90th day, the application will be denied.

b. Refer to MA-2220, State Residence, and MA-2350, Certification and Authorization, for procedures.

K. Medicaid Identification Card

Refer to MA-2380, Medicaid Identification Card.

Explain to the applicant or his representative the annual Medicaid identification card and how to use it. Explain that he should keep the card even if his eligibility terminates because he may become eligible again and be able to use the same card. Explain to the PACE applicant that a Medicaid card is not issued. Refer to MA-2275, Program of All-Inclusive Care for the Elderly (PACE).

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