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

VI. EXPLAINING THE AVAILABLE SERVICES

When an individual applies at the county department of social services for an adult Medicaid aid program/category, give the applicant a copy of the handbook, “A Consumer’s Guide to North Carolina Medicaid Health Insurance Programs for the Aged, Blind, and Disabled” and/or “A Consumer’s Guide to Medicare Savings Programs Within North Carolina Medicaid.”

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(VI.)

Explain to the applicant that the handbook is to be kept as a reference guide because it lists the services covered by Medicaid, how to use the Medicaid card and other helpful information about services available through Medicaid.

A. Community Care of North Carolina/Carolina Access (CCNC/CA)

Refer to MA-2425, Community Care of North Carolina/Carolina Access (CCNC/CA), to determine if the assistance unit members are required to participate and to explain the service.

CCNC/CA provides the Medicaid recipient with a medical home and Primary Care Provider (PCP) who manages care for continuity and ensures services are provided that are medically necessary.

B. Pregnancy Medical Home (PMH)

PMH provides additional obstetric care to pregnant Medicaid recipients with the goal of improving the quality of maternal care, improving birth outcomes, providing continuity of care and 24 hour provider availability to the recipient. Each recipient receives an initial screening at their first doctor’s visit. If a recipient is identified as high risk, she is referred for a thorough assessment by a care manager. The recipient’s level of need is determined by the care manager assigned to the PMH. Care managers closely monitor the pregnancy through regular contact with the physician and recipient to promote a healthy birth outcome.

If a pregnant Medicaid recipient’s aid program category covers pregnancy, she is eligible to participate in this program. This program is NOT just for MPW. In addition, any provider who bills global, package or individual pregnancy procedures can participate in this program as long as he agrees to the program requirements. It is not just for OB providers.

1. Caseworker Responsibilities

a. Explain the benefits of using a Pregnancy Medical Home (PMH).

b. Give a copy of the DMA-5076/DMA-5076S, PMH handout at each application and redetermination to all pregnant Medicaid applicants/recipients.

c. Encourage all pregnant Medicaid recipients to use a PMH.

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(VI.B.1.)

d. Review with the recipients the PMHs available in their county and surrounding counties, if there are none in their county. (See 2 below for Provider Directory information). Do not link pregnant Medicaid recipients participating in the PMH program to a PMH provider on the Medicaid card unless the PMH is also the recipient’s PCP.

2. Provider Directory

A monthly report “DHREJA-PREGMED-HOME-PROVDIR,” summarizing any changes in the PMH providers is available in XPTR the first workday of each month. (Refer to EIS 1061 for instructions on accessing XPTR reports).

A designated dss employee such as a Medicaid supervisor, caseworker, administrative or clerical staff is responsible for running the report and maintaining a county PMH directory that can be printed or viewed on line. The directory contains all information necessary to assist the recipient in choosing a PMH including provider specialty and location. (Refer to EIS 1061 for reports.)

C. Covered Services

Refer to MA-2905, Medicaid Covered Services.

Explain the Health Check program and Family Planning Services.

1. Health Check pays for health care for children under age 21, who are authorized for Medicaid in any aid program/category except M-QB and those who receive emergency Medicaid only.

a. Review the services available and how to obtain them. Explain that transportation to medical appointments and assistance in locating a provider are also available.

b. Explain that letters will be sent to their home reminding them of services available through the Health Check program and of upcoming scheduled appointments.

c. If the county has a Health Check Coordinator, give the individual his or her name and phone number. Explain that the Health Check Coordinator can answer questions, help with locating a provider and help with scheduling appointments.

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(VI. C.)

2. Explain Family Planning Services

Family planning services are available to any family member (either male or female) of childbearing age, including minors. Services may include counseling, education, birth control and medical examinations.

a. Explain the limitations on abortions and sterilizations.

b. Explain that the individual’s decision regarding family planning does not have an effect on Medicaid eligibility.

c. If services are requested, refer to the appropriate individual or agency in your county.

3. Medical Transportation

Refer to MA-2910, Medicaid Transportation, for specific information concerning medical transportation.

a. Inform the individual that if he does not have or cannot arrange medical transportation on his own, he is entitled to help from the DSS in arranging and/or paying for medical transportation when he is authorized for Medicaid. It does not apply to individuals authorized for M-QB or NC Health Choice.

b. Explain to the individual that the DSS will not provide transportation to a provider of the individual’s choice (except for CA providers) when a local provider is available.

c. Give the individual the DMA-5046, Medical Transportation Assistance Notice of Rights, along with the contact information for the person or unit in the agency that handles transportation requests. Explain his right to request assistance with medical transportation. File a copy of the DMA-5056, Medical Transportation Assistance Notice of Rights, in the case record.

4. Other Covered Services

For information about other covered services, including Adult Health Screenings, refer the individual to the handbook “A Consumer’s Guide to North Carolina Medicaid Health Insurance Programs for the Aged, Blind, and Disabled.”

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(VI.)

D. Food and Nutrition Services

Ask the individual if the family receives Food and Nutrition Services.

1. If the family receives, has applied for or would like to apply for Food and Nutrition Services, you must notify the Food and Nutrition Services office of the status of the Medicaid application. Use the DSS-8194, Income Maintenance Transmittal Form, to notify the Food and Nutrition Services office.

2. If an individual does not receive Food and Nutrition Services, inform him that the program is offered and provide him with instructions for applying.

E. Women, Infants and Children Program (WIC)

WIC is a supplemental food and nutrition education program that provides supplemental foods to improve diets and reduce chances of health problems by poor nutrition. WIC foods include infant formula, milk, eggs, cheese, juice (including infant juice), cereal (including infant cereal), and dry beans and peas.

1. The program serves:

a. Pregnant women, and

b. Postpartum women (up to 6 months after delivery), and

c. Women who are breastfeeding, and

d. Children under six years of age.

2. If the individual is interested in the WIC program, make a referral to the local WIC agency.

F. Lifeline/Link-Up Assistance Program

The Lifeline Assistance Program is designed to promote universal service by helping low-income individuals afford telephone service and to receive a credit on their monthly telephone bill.

Lifeline provides a monthly discount on an eligible recipient’s local telephone bill. If the recipient does not have a telephone, Link-Up provides a 50% discount, up to $30, on the cost of connecting local telephone service. Only one Lifeline benefit is available per household. Long distance call blocking is available to Lifeline recipients at no charge upon request. If the individual receives any one of the public assistance benefits listed below he can receive Lifeline/Link-Up benefits.

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(VI. F. 3.)

To be eligible for Life Line/Link Up the individual must receive Medicaid under MAF, MPW, MAABD, MQB-Q, MQB-B or MQB-E and receive telephone service listed in his name from one of the telephone companies listed on the DMA-5058, Participating Telephone Service Providers.

NOTE: MIC, HSF, IAS, and FPW recipients are ineligible for Lifeline/Link-up.

The North Carolina Utilities Commission recently approved a Self-Certification process for recipients of low income programs to use when applying for Lifeline/Link-up benefits. The application form is the DSS-8168-I, North Carolina Life Line/Link-Up Self-Certification Letter.

The caseworker must provide applicants/recipients information on Lifeline/Link-Up and provide households with the address of their participating telephone service provider (see DMA-5058). Instruct households to complete the DSS-8168-I and mail it to their telephone service provider if they meet the eligibility requirements for Lifeline/Link-Up.

If a household requests assistance with completing or mailing the DSS-8168-I, the assigned Medicaid caseworker for that individual must complete the form, and return it to the appropriate provider.

Recipients requesting new telephone service must apply for Lifeline/Link-Up directly with the telephone company.

Upon receipt of the Lifeline and/or Link-Up Application, DSS-8168-I, the telephone company verifies the recipient’s name and telephone number and keys the information into its system. The recipient receives the credit with his next billing cycle.

Upon receipt of the DSS-8168I, the telephone company verifies the recipient’s name and telephone number and keys the information into its system. The recipient receives the credit with his next billing cycle.

G. National Voter Registration Act (NVRA)

The purpose of the NVRA is to make available more opportunities for people to vote. Ensure voter registration forms are available to individuals during their visits. If the individual asks for assistance in completing the voter registration form, provide the assistance. Inform the individual that the Board of Elections processes applications to register to vote. Questions concerning voter registration must be directed to the local Board of Elections.

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(VI. 4)

H. Certificate of Creditable Coverage

The Health Insurance Portability and Accountability Act (HIPAA) requires that group plans and health insurance issuers, including Medicaid, who offer group coverage furnish certificates of creditable coverage when an individual ceases to be covered by the plan. The purpose of the certificate of creditable coverage is to present evidence that the individual had prior creditable coverage that will reduce or eliminate pre-existing exclusions under subsequent health coverage. Health plans that impose pre-existing condition exclusions must reduce the length of an exclusion period by an individual's creditable coverage.

The issuance of the certificates is automated and is done by DMA’s fiscal contractor when a recipient is terminated. Certificates can be provided up to 24 months after termination. If an individual has questions about a Certificate of Creditable Coverage refer him to HP formerly (EDS) at 1-800-688-6696 or Automated Voice Response (AVR) at 1-800-723-4337.

I. Health Insurance Premium Payment (HIPP)

1. HIPP is a program in which the Division of Medical Assistance (DMA) pays private health insurance premiums for Medicaid recipients when it is cost effective to do so. Cost effectiveness is established when the annual cost of the premiums, deductibles and coinsurance is less than the anticipated Medicaid expenditures.

HIPP is most cost effective for Medicaid recipients with catastrophic illnesses such as end stage renal disease, chronic heart problems, congenital birth defects, cancer, or AIDS.

2. To be eligible for the premium payment, the recipient must be authorized for Medicaid and have private health insurance. DMA only pays premiums on existing or known policies. DMA does not find new coverage for a recipient. Premiums may be paid for a family coverage policy when the policy is cost effective and it is the only way the recipient can be covered by the policy. Family members that are not Medicaid recipients do not receive Medicaid payment of deductible, coinsurance or cost sharing obligations.

HIPP is not available to individuals in deductible status. DMA no longer pays the health insurance premium when a recipient is placed in deductible status at redetermination or due to a change in situation.

3. When DMA determines that a group health insurance plan available to a recipient through an employer is cost effective, the recipient is required to participate in the plan as a condition of eligibility for Medicaid.

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(VI.I.3.)

a. If the recipient voluntarily drops the insurance coverage, Medicaid benefits may be terminated.

b. The recipient is not required to enroll in a plan that is not a group health insurance plan through an employer. However, if it is determined that the policy is cost effective, DMA pays the cost of premiums, coinsurance and deductibles of non-group health plans if the recipient chooses to participate.

4. Referrals

a. Give a brochure, and the DMA-2069, Health Insurance Premium Payment Application Form, to any recipient who has a qualifying catastrophic illness.

b. Assist the recipient in completing the form and advise him to have the physician submit any requested medical record.

c. Ask the recipient to return the completed form to the county dss for submission to DMA.

Submit the completed forms to:

Attn: NC HIPP

4441 Six Forks Rd, Suite 106-227

Raleigh, NC  27609

d. In addition to county dss referrals, DMA provides HIPP program information to recipients by placing brochures and applicable forms in local health departments, hospitals, hospices, and physicians’ offices.

5. Recipients who request assistance through the HIPP program are notified in writing within 30 days of the outcome of the request. For recipients who are approved, health insurance premiums cannot be applied to the deductible or allowed as an unmet medical need effective the month DMA begins paying the premium.

J. Children with Special Health Care Needs

If the DMA-5063, Application for Health Check/Health Choice, shows a child has a special health care need, enter the appropriate special needs code in the individual data on the DSS-8125. EIS automatically inserts a Special Needs code for individuals in certain aid program/categories. The caseworker has the responsibility for keying the Special Needs code for other aid program/categories. See EIS 4000, Codes Appendix.