Adult Medicaid Manual MA-2320 REDETERMINATION OF ELIGIBILITY

XXI. REDETERMINATION ALTERNATIVES

A. The following methods for completing reviews have been developed as suggested alternatives to the one-on-one interview:

1. Group Interview

2. Telephone Call

3. Mail

B. The recipient must be notified and agree to the alternative method of completing the review. Refer to D.2. below for scheduling the review.

C. Selection of Cases for Alternative Review

1. Determining When a Review is Due

Start the process in the 4^th month of a 6^th month coverage period or the 10^th month of a 12 month coverage period.

2. Selection of Individuals to Participate

Once you have determined those individuals due for a review, you must determine the best candidates to participate in the alternative methods of completing the review.

a. Screening and Selecting Cases

(1) Review the case record(s) to determine if the recipient can read, write and function with minimal supervision.

REISSUED 03/01/11 – CHANGE NO. 03-11

(XXI.C.2.a.)

(2) Look at previous signature, educational level and other problems noted in the record that would prevent the recipient from participating in one of the alternate methods for completing reviews. For example, if the recipient signed the previous review forms with an “X”, this indicates that the individual may be unable to write. Also, if the educational level is documented in the record as being ninth grade or below, the recipient MAY NOT be a good candidate for the alternate review.

(3) If the IMC is unsure whether to include the recipient in one of the alternative methods for completing reviews, ask for input from the supervisor.

b. Include the following categories in the group interview:

(1) CNNMP recipients, and

(2) Deductible cases,

c. Exclude the following:

(1) LTC population, except when a representative is noted in the record, and

(2) Dual Aid/Program category cases, example MAABD/MQB

D. Setting Up The Alternative Review/Redetermination

1. Once cases have been identified that are due for a review and the method of completing the review has been selected, the IMC must:

a. Review the case record(s) to determine items needed to complete the review, including the reserve history sheet.

b. Complete the following checks prior to the review:

(1) On-line computer matches,

(2) Property checks, and

(3) Records at the clerk of court.

2. Scheduling The Review

a. Send the review notice DSS-8189, Appointment Notice, to schedule the review.

(1) Notify the recipient on the notice how the review will be completed and that he can decline the review being completed by the alternative method but he must notify the IMC within 5 workdays of his decision not to participate.

REISSUED 03/01/11 – CHANGE NO. 03-11

(XXI.D.2.a.)

(2) Notify the recipient of items needed to complete the review.

(3) State the time and place on the notice or the scheduled time you will call to complete the review or when the self complete form must be returned.

b. Reserve conference room if a group interview.

E. The Group Review/Redetermination

1. Setting up the Group Review

a. Arrange for one IMC to be the facilitator of the group and one IMC to monitor the group.

b. Allow at least 1-1/2 hours to complete the group interview.

c. It is suggested that you schedule no more than 25 people for the group interview.

2. Procedures

a. The Interview

(1) Start the review no later than 15 minutes from the appointed time.

(2) Explain to the group that the information they give is personal and should be kept confidential. Any questions that are specific in nature should be held until the end of the session and will be discussed individually and answered at that time.

(3) Refer to III. through XVIII. above for detailed information that should be addressed during the group interview.

b. Completion of the Group Interview

(1) At the end of the group session, check each review form to insure all questions have been answered and no additional items are necessary to complete the review before the recipient leaves the interview.

(2) Answer any questions that are specific to a case in a private one-on-one situation.

(a) Send a timely notice to the recipient notifying of the termination for Medicaid.

(b) Refer to the appropriate section for notice requirements and procedures.

REISSUED 03/01/11 – CHANGE NO. 03-11

(XXI.E.2.)

c. Documentation

Document the case record when:

(1) The recipient failed to show up for the review.

(2) You have determined that the situation has not changed. Send the appropriate notice.

(3) You have determined that the situation has changed. Send the appropriate notice.

(4) The recipient failed to provide information which is his responsibility or when collaterals failed to respond to request for information by deadline. Send the appropriate notice.

F. The Telephone Call Review

1. Steps in Setting up the Telephone Interview

The telephone review can be accomplished in two ways. One by sending the review notice to the client and letting the recipient complete the form while telephone interview is being completed or the IMC can keep the review form and complete the review form while interviewing the recipient on the telephone.

a. Review the case record(s) to identify items needed to complete the review, including the reserve history sheet.

b. Send the review notice, DSS-8189, Appointment Notice, review form (if the recipient is completing the form) and a self addressed envelope to the recipient to schedule the telephone review.

NOTE: State the time on the notice that you will call the recipient to complete the telephone interview. Notify the recipient on the notice that the review will be completed by telephone and allow the recipient the opportunity to decline the review being completed by a telephone call or to change the time of the telephone review.

c. Notify the recipient of items needed to complete the review. Use the DMA-5097/5097S, Request for Information. If the information is not received, send a timely notice. The case will be terminated for Medicaid after the timely notice is sent.

REISSUED 03/01/11 – CHANGE NO. 03-11

(XXI.F.2.)

2. Conducting the Telephone Interview

All items necessary for completing the telephone interview should be present before calling the recipient for the telephone review.

a. Procedures

(1) Call the recipient at the appointed time.

(2) Refer to III. through XVIII. above for detailed information that should be addressed during the telephone interview.

b. Completion of the Telephone Review

(1) If the recipient completed the review form, ask the recipient to sign the review form and mail the form in the self addressed envelope within ten workdays or the case will be terminated for Medicaid.

(2) If the IMC completed the review form, notify the recipient that he will receive the review form in the mail and he must sign the form and return the form within ten workdays or the case will be terminated for Medicaid.

c. Documentation

Document the case record when:

(1) The recipient fails to keep the telephone review appointment.

(a) Send a timely notice to the recipient notifying of the termination for Medicaid.

(b) Refer to the appropriate section for notice requirements and procedures.

(2) You have determined that the situation has not changed. Send the appropriate notice.

(3) You have determined that the situation has changed. Send the appropriate notice.

(4) The recipient failed to provide information which is his responsibility or when collaterals failed to respond to request for information by deadline. Send the appropriate notice.

REISSUED 03/01/11 – CHANGE NO. 03-11

(XXI.)

G. Redetermination by Mail

At county option, the DMA-5007MR may be used for mail reviews of Aged, Blind and Disabled Medicaid eligibility when the assistance unit is authorized without a deductible.

1. Criteria for Selecting Cases Reviewed by Mail

a. Cases reviewed by mail must be one of the following:

(1) PLA MAABD(N) Cases

(2) All Non-SSI LTC Cases

(3) MQB-Q and MQB-B Cases -- authorized for MQB which have not met a deductible for MAABD in the last past six months and which have not submitted enough bills to indicate the current deductible will be met.

AND

b. Must meet all of the following criteria:

(1) Only source of income is predictable (RSDI, VA, Civil Service Retirement, NC State Retirement, etc.).

(2) The a/r does not have to meet a deductible (may have a PML if LTC).

(3) Total countable assets at last determination of eligibility were $1,700 or less.

(4) All match reports (including FRR) have been verified and considered.

(5) Assets are not questionable due to an unsettled estate or due to alleged incompetence.

c. Do not include the following types of cases:

(1) MAABD-MN cases with a deductible

(2) MQB cases which meet the deductible and transfer to MAABD-Q/B

(3) Cases with unstable unearned income or rental property

(4) Cases with earned income (wages, etc.)

(5) Cases in which the casehead is known to be illiterate, or does not speak English and does not have an authorized representative that acts for the recipient.

(6) SSI cases (not reviewed)

REISSUED 03/01/11 – CHANGE NO. 03-11

(XXI.G.)

2. Preparation for Mail Review

a. Identify cases to be included which meet the criteria in G.1., above.

b. Initiate verifications

(1) Review the most current case information to identify verifications needed to complete the review, including reserve history sheet. Remember to update the reserve history sheet if there is a change.

(2) Request needed third party verifications.

c. Date of the letter (date the form will be mailed).

3. Complete the cover page of the DMA-5007MR with the following:

a. Name and address of person expected to complete the form (either the recipient, or if he cannot complete the review, his representative).

b. Check each block which applies to information or verifications needed and write in any other information needed from the client not listed.

c. “Return No Later” date—should be ten work days from the date the form is mailed to the casehead. This is the date that the form must be returned signed with all items completed.

d. Include the following with the form:

(1) Release of information to be signed and returned, and

(2) A pre-addressed return envelope. Write or stamp “Review or Re-enrollment” and the IMC’s name on the envelope, and

(3) Telephone number where the IMC can be reached.

4. Contact the recipient or his representative.

a. Mail contact, followed by telephone contact:

(1) Send DMA-5007MR to the recipient or representative no later than the first work day of the fifth/eleventh month of the current certification period; and

REISSUED 10/01/11 – CHANGE NO. 18-11

(XXI.G.4.a.)

(2) Contact the recipient or representative by phone when the DMA-5007MR is returned to the dss. Explain the services available. Make at least two attempts to reach the recipient or representative by phone on two different days. If unsuccessful, request any needed information or clarification by mail, attaching a notice of proposed termination, giving ten work days to provide the information.

OR

b. Complete the form during a telephone interview and mail for signature on the same day the interview is conducted.

5. To comply with the review requirements, the casehead/representative must:

a. Return requested information.

b. Provide a current telephone number where the recipient or representative may be reached during the daytime.

c. Name all current members of the PLA recipient’s household.

d. Provide information regarding unmet medical expenses of the LTC recipient and income of the community spouse.

e. Read their rights and responsibilities information and sign the form. When the telephone contact is made, the worker should ask specifically about services and explain this section of the form.

f. Either return the form to the county dss no later than the date indicated on the cover letter of the DMA-5007MR or contact the county for an appointment to conduct the review in person.

6. Propose termination of the case using a timely notice if:

a. The client or the representative does not respond either by returning the DMA-5007MR by the “Return No Later” date, or by contacting dss (by phone, letter, or in person) to request an interview by that date. Do not send another form. An automated timely notice can be used for proposed termination notice.

OR

REISSUED 03/01/11 – CHANGE NO. 03-11

(XXI.G.6.)

b. The form when returned is not signed, is incomplete, or information is missing which the IMC requested on the DMA-5007MR and which cannot be obtained any other way. Copy the form for your record and re-mail original with a manual timely notice attached, proposing termination unless it is completed, signed, and returned within ten (10) work days.

OR

c. Ineligibility is established. Send an automated timely notice.

OR

d. The client requests an interview, but does not keep the appointment. Send an automated timely notice.