NC DEPARTMENT OF HEALTH AND HUMAN SERVICES EIS MANUAL

ELIGIBILITY INFORMATION SYSTEM EIS 4000

-----------------------------------------------------------------------

CODES APPENDIX B - MEDICAID CODES

-----------------------------------------------------------------------

EIS 4000 – CODES APPENDIX B – MEDICAID CODES

CHANGE CODES - MEDICAID CHANGES

REDETERMINATION NOTICES WITH NO CHANGES IN BENEFITS

REDETERMINATION NOTICES WITH NO CHANGES IN BENEFITS FOR NON-SSI CASES WITH A CERT. THROUGH DATE OF 12/31/9999.

REDETERMINATION NOTICES WITH NO CHANGES IN BENEFITS FOR NON-SSI CASES WITH A CERT. THROUGH DATE OF 12/31/9999 (CONT’D)

DISPOSITION CODES - MEDICAL ASSISTANCE APPROVALS

DISPOSITION CODES - MEDICAL ASSISTANCE DENIALS(G8 IS THE ONLY DENIAL CODE FOR M-SB CASES.)

DISPOSITION CODES – MEDICAL ASSISTANCE WITHDRAWALS

MEDICAID TERMINATION CODES

TRANSFERS (AID PROGRAM/CATEGORY)

**NOTE: NC HEALTH CHOICE CODES ARE LOCATED IN EIS-4300 PART SIX.**

NOTE: USE SPECIFIC BREAST AND CERVICAL CANCER MEDICAID (BCCM) CODES AS INDICATED. IF A SPECIFIC BCCM CODE IS NOT AVAILABLE, USE THE APPROPRIATE MAF CODE.

DISPOSITION CODES

TERMINATIONS

TRANSFERS (AID PROGRAM/CATEGORY)

EIS 4000 – CODES APPENDIX B – MEDICAID CODES

REISSUED 01/01/06 – CHANGE NO. 03-06

CHANGE CODES - MEDICAID CHANGES

NOTE: DO NOT USE THESE CODES FOR NC HEALTH CHOICE. NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

DSS-8110A

Based on the “ADEQUATE” or “TIMELY” change code entered on the
DSS-8125, EIS generates an automated notice for Medicaid benefit case actions. The notice contains the following information:

1. “ADEQUATE” or “TIMELY” is indicated at the top of notice.

2. “THE CHANGE WHICH WILL TAKE PLACE:”

a. “Effective on MM/DD/CCYY” (This date will be the Medicaid Effective Date, Individual Termination Date or Individual Date of Death).

b. When an individual termination date or date of death is present, the following will print:

“(Name of individual) This individual(s) is being terminated from your case” or “This individual(s) was deleted because of death.”

c. If the case is in authorized status, the following will print:

“You are eligible for the following months:”

“MM/DD/CCYY - MM/DD/CCYY.”

d. If the case is in deductible status, the following will print:

“You will not receive another Medicaid card until you meet your deductible for the following months:”

“MM/DD/CCYY thru MM/DD/CCYY $_____ is your Medicaid deductible.”

e. If a PML is present, the following will print:

“$_____ is your monthly liability.”

“You must pay your liability to the nursing home each month.”

f. If Medicaid classification changes to “Q”, “B”, or “E”, the following will print:

“MM/DD/CCYY Medicaid will pay your Medicare premiums.”

REVISED 01/01/06 – CHANGE NO. 03-06

MA CHANGE CODES (CONT'D)

g. If the program is MQB AND the Medicaid classification changes from “Q” to “B” or “E”, or

If the case changes from Authorized to Deductible status AND the Medicaid classification changes from “Q” to “M”, or

If the case changes from “Q” to “N”, the following will print:

“Medicaid will continue to pay your Medicare Part B premium. However, Medicaid will stop paying your Medicare Part A premium, if applicable. You will no longer receive a Medicaid card.”

h. If the Medicaid classification changes to “D”, the following will print:

“Your coverage is limited to Family Planning Waiver services. Your partner may be potentially eligible also.”

3. “WHY THE CHANGE WILL BE MADE:”

A reason that will correspond to the Change Code keyed will print followed by the sentence:

“State rules supporting this action are found in Section _________ of the __________ Manual.”

The appropriate section from the corresponding manual will be inserted. Based on the aid program/category, the manual title will be the Aged, Blind, and Disabled Medicaid Manual or the Family and Children's Medicaid Manual.

4. “WHEN THE CHANGE WILL BE MADE:”

a. If the change code entered is an “ADEQUATE” code, the notice will state;

“The change will be effective on MM/DD/CCYY.”

b. If the change code entered is a TIMELY code, the notice will state;

“The change will be effective on MM/DD/CCYY which is 10 workdays from the date of this letter, unless you ask for a hearing on or before that date.”

REISSUED 01/01/06 – CHANGE NO. 03-06

MA CHANGE CODES (CONT’D)

INCOME, NEEDS

EITHER LTC OR PLA - NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

PLA - NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

REISSUED 01/01/06 – CHANGE NO. 03-06

MA CHANGE CODES (CONT’D)

LTC NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

CHANGE FROM AUTHORIZED TO DEDUCTIBLE AT REVIEW

PLA

REISSUED 3/01/10 – CHANGE NO. 03-10

MA CHANGE CODES (CONT’D)

DELETIONS OF INDIVIDUAL(S) - NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

REVISED 3/01/10 – CHANGE NO. 03-10

DELETIONS OF INDIVIDUAL(S) (CONT’D) NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

CONTINUATION OF PRESUMPTIVE ELIGIBILITY COVERAGE

REVISED 02/01/11 – CHANGE NO. 03-11

MA CHANGE CODES (CONT’D) NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

CHANGE IN MEDICAID CLASSIFICATION FROM ‘B’ or ‘E’ TO ‘Q’ (MQB ONLY)

CHANGE IN MEDICAID CLASSIFICATION FROM “N” OR “M” TO “Q”

CHANGE IN BREAST AND CERVICAL CANCER MEDICAID CLASSIFICATION FROM MAF ‘W’ or ‘T’ TO MAF ‘N’ or ‘M’

CHANGE IN MEDICARE A AND/OR B STATUS (EXCEPT MQB)

SUSPENSION DUE TO INCARCERATION OR IN AN IMD

REASON	TIMELY	ADEQUATE
Your Medicaid benefits will be suspended because you are incarcerated. Your Medicaid coverage is limited to payment of medical services related to an inpatient hospital stay. No card will be issued. (DMA Administrative Letter No. 09-08)	N/A	9I
Your Medicaid benefits will be suspended because you are in an Institution for Mental Diseases. You will not have any Medicaid coverage during the suspension. No card will be issued. (DMA Administrative Letter No. 09-08)	N/A	9L

REVISED 02/01/11 – CHANGE NO. 03-11

MA CHANGE CODES (CONT’D) NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX

SUSPENSIONS DUE TO INCARCERATION OR IN AN IMD (CONT’D)

REASON	TIMELY	ADEQUATE
Moves from incarceration to IMD: Your Medicaid benefits will remain in suspension because you are now in an Institution for Mental Diseases. You will not have any Medicaid coverage during the suspension. No card will be issued. (DMA Administrative Letter No. 09-08)	N/A	9P
Moves from IMD to incarceration: Your Medicaid benefits will remain in suspension because you are now incarcerated. Your Medicaid coverage is limited to payment of medical services related to an inpatient stay. No card will be issued. (DMA Administrative Letter No. 09-08)	N/A	9S
Your Medicaid benefits were suspended while you were incarcerated. Your Medicaid benefits have now been released from suspension. (DMA Administrative Letter No. 09-08)	N/A	9U
Your Medicaid benefits were suspended while you were in an Institution for Mental Diseases. Your Medicaid benefits have now been released from suspension. (DMA Administrative Letter No. 09-08)	N/A	9V

OTHER - NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

REISSUED 03/01/10 – CHANGE NO. 03-10

MA CHANGE CODES – OTHER (CONT’D) NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX

NOTE: SEE EIS 2500 FOR ALL PACE NOTICES AND CODES.

REISSUED 05/01/09 – CHANGE NO. 03-09

REDETERMINATION NOTICES WITH NO CHANGES IN BENEFITS

NOTE: DO NOT USE THESE CODES FOR NC HEALTH CHOICE. NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

DSS-8108A

Enter a change code “01” for all Medicaid redeterminations on the
DSS-8125 when completing a review with no changes in benefit. This code can be used when changing data including income, maintenance amount, and/or needs unit. This also includes changes from MIC-1 to MIC-N or from MIC-N to MIC-1 as they are the same benefit for the recipient. Refer to the appropriate transfer code if the aid program/category is changed. EIS will produce a notice to say:

1. “The Medicaid benefit you were receiving continues.”

2. If the case is in authorized status, the following statement will print:

“You are eligible for the following months:"

“MM/DD/CCYY thru MM/DD/CCYY”

3. If the case was in deductible status and remains in deductible status after the review is completed, the following statement will print:

“You will not receive another Medicaid card until you meet your deductible for the following months:”

“MM/DD/CCYY thru MM/DD/CCYY $_____ is your Medicaid deductible.”

4. If a PML is present and did not change:

“$_____ is your monthly liability. You must pay your liability to the nursing home each month.”

5. For MQB-E cases the notice text will read:

“Medicaid will continue to pay your Medicare Part B Premium from XX/XX/XXXX to XX/XX/XXXX.”

6. “State rules supporting this action are found in Section ________ of the ________Manual.”

Based upon the aid program/category, this will either be Section 2000 of the Aged, Blind, and Disabled Medicaid Manual or Sections 3230 and 3235 of the Family and Children's Medicaid Manual.

REISSUED 05/01/09 – CHANGE NO. 03-09

REDETERMINATION NOTICES WITH NO CHANGES IN BENEFITS (CONT’D)

7. If you are authorizing PACE at review, the text will read as follows:

a. “PACE/Medicaid application approved.”

b. Followed by:

“The following individuals (s) are approved on

this application:”

Name

c. “________ is the PACE effective date.”

d. Because all PACE cases must have a PML, even if it is zero, the following text will appear:

“$_______ is your monthly liability. You must pay your liability to the nursing home or your PACE center each month.”

e. Followed by:

“You meet all eligibility requirements.”

f. “State rules supporting this section are found in Section 2000 and 2304 of the Aged, Blind, and Disabled Medicaid Manual.”

REISSUED 05/01/09 – CHANGE NO. 03-09

REDETERMINATION NOTICES WITH NO CHANGES IN BENEFITS FOR NON-SSI CASES WITH A CERT. THROUGH DATE OF 12/31/9999.

NOTE: DO NOT USE THESE CODES FOR NC HEALTH CHOICE. NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

DSS-8108A

Enter a change code “96” for MAABD or HSF redeterminations on the DSS-8125 when completing a review with no change in benefit for Non-SSI cases with the certification through date of 12/31/9999. This code can be used when changing data including income and maintenance amount. Refer to the appropriate transfer code if the aid program/category is changed.

EIS will produce a notice to say:

1. “The Medicaid benefit you were receiving continues.”

2. If the case is in authorized status, the following statement will print:

“You are eligible for the following months:”

“MM/DD/CCYY - MM/DD/CCYY”

3. If the case is in deductible status after the review is completed, the following statement will print:

“You will not receive another Medicaid card until you meet your deductible for the following months:”

“MM/DD/CCYY thru MM/DD/CCYY $_______ is your Medicaid deductible.”

4. If a PML is present and did not change:

“$_____ is your monthly liability. You must pay your liability to the nursing home each month.”

5. “State rules supporting this action are found in Section __________ of the ________ Manual.”

Based upon the aid program/category, this will either be Section 2000 of the Aged, Blind, and Disabled Medicaid Manual, or Section 3420 of the Family and Children’s Medicaid Manual.

6. If you are authorizing PACE at review, the text will read as follows:

a. “PACE/Medicaid application approved.”

REISSUED 10/01/09 – CHANGE NO. 01-10

REDETERMINATION NOTICES WITH NO CHANGES IN BENEFITS FOR NON-SSI CASES WITH A CERT. THROUGH DATE OF 12/31/9999 (CONT’D)

b. Followed by:

“The following individuals (s) are approved on this application:”

Name

c. “________ is the PACE effective date.”

d. Because all PACE cases must have a PML, even if it is zero, the following text will appear.

“$_______ is your monthly liability. You must pay your liability to the nursing home or your PACE center each month.”

e. Followed by:

“You meet all eligibility requirements.”

f. “State rules supporting this section are found in Section 2000 and 2304 of the Aged, Blind, and Disabled Medicaid Manual.”

REVISED 10/01/09 – CHANGE NO. 01-10

DISPOSITION CODES - MEDICAL ASSISTANCE APPROVALS

(MRF CASES REQUIRE A MANUAL NOTICE.)

NOTE: DO NOT USE THESE CODES FOR NC HEALTH CHOICE. NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

ONGOING APPROVALS (APPLICATION TYPES “1”, “2”, “3”, “4”, “5”, “6”, AND “7”)

1. The reason code entered as the application disposition reason will determine the text to be printed on the automated 8108A.

2. The text will be:

“This is to notify you that your Medicaid has been approved.”

3. Followed by:

“The following individuals are approved on this application:”

Name of Individual and Individual ID number.

4. “You are eligible for the following months:”

MMDDCCYY thru MMDDCCYY [Retro MA 1]

MMDDCCYY thru MMDDCCYY [Retro MA 2]

MMDDCCYY thru MMDDCCYY [Ongoing]

5. If a patient monthly liability(ies) is/are present, the following text will be printed:

“$_____ is your monthly liability [up to three PML's]. You must pay your liability to the nursing home each month."

6. If Medicaid classification of “D” is entered, the following text will print:

“Your coverage is limited to Family Planning Waiver services. Your partner may be potentially eligible also.”

7. If Medicaid classification of “Q” is entered (and there was no previous eligibility with Medicaid classification of C, N, or M), the following text will be printed:

“Medicaid will pay your Medicare premiums.”

REISSUED 05/01/09 – CHANGE NO. 03-09

ONGOING MA APPROVAL NOTICE TEXT (CONT'D)

8. If Medicaid classification of F, H, O, or R is entered, the following text will print:

“Your coverage is limited to the above dates on which you had a medical emergency.”

9. If Medicare B was entered as “Y”, the Buy-In Effective Date and the following message will be printed:

“MMDDCCYY The state will begin paying your Medicare B premium.”

10. If Medicare A and/or B was entered as “Y”, the following message will be printed:

“If you receive Medicare, Medicare is responsible for your prescriptions.”

11. The text associated with the disposition reason code entered.

12. “State rules supporting this action are found in Section ______ of the _______ Manual.”

The appropriate section from the corresponding manual will be inserted. Based on the aid program/category, the manual will be the Aged, Blind, and Disabled Medicaid Manual or the Family and Children's Medicaid Manual.

13. If the case is a PACE approval, the text will read as follows:

a. “PACE/Medicaid application approved.”

b. Followed by:

“The following individuals (s) are approved on this application:”

Name

c. “________ is the PACE effective date.”

d. Because all PACE cases must have a PML, even if it is zero, the following text will appear:

“$_______ is your monthly liability. You must pay your liability to the nursing home or your PACE center each month.”

REISSUED 05/01/09 – CHANGE NO. 03-09

ONGOING MA APPROVAL NOTICE TEXT (CONT’D)

e. Followed by:

“You meet all eligibility requirements.”

f. “State rules supporting this action are found in Section 2000 and 2304 of Aged, Blind, and Disabled Medicaid Manual.”

OPEN/SHUT APPROVAL NOTICE TEXT

In addition to text indicated in 1 and 2 above, the following text will print.

1. “All Medicaid benefits will stop.”

2. If Medicare B was entered as “Y”:

“Medicaid will stop paying your Medicare Part B premium.”

3. The text associated with the termination code will print. Refer to Termination Codes.

REVISED 03/01/10 – CHANGE NO. 03-10

MA APPROVAL CODES (CONT’D)

APPROVAL CODES FOR MEDICAID CASES - NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

ALL INDIVIDUALS WHO APPLIED ARE APPROVED IN SAME CASE

A1	You meet all eligibility requirements. (Section 2000 and 2304 of the Aged, Blind, and Disabled Manual or Section 3215 and 3230 of the Family and Children's Manual.)
B8	The following individual(s) is approved for Medicaid for the months of ____ thru ______. You must provide verification of citizenship and/or identity to continue to receive Medicaid. If documentation is not received, your Medicaid will be terminated. (Section MA-2505/3331)

APPROVAL OF MQB-B OR MQB-E COVERAGE

B4	You are eligible only for payment of Medicare Part B premiums because your income exceeds the limit for full Medicaid coverage. (Sections 2140 and 2160 of the Aged, Blind, and Disabled Manual.)

NOT ALL INDIVIDUALS APPROVED ON CASE - NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

A2	This individual(s) meets all eligibility requirements. Medicaid benefits for all others on the application have been approved in another case. (Section 3215 and 3230 of the Family and Children's Manual.)
A4	This individual(s) meets all eligibility requirements. Medicaid benefits for all others on the application have been denied. (Section 3215 and 3230 of the Family and Children's Manual.)

NOTE: YOU MUST USE A SECONDARY NOTICE CODE OR NOTICE TEXT TO INDICATE THE REASON FOR DENIAL OF INDIVIDUALS NOT INCLUDED.

REISSUED 03/01/10 – CHANGE NO. 03-10

MA APPROVAL CODES (CONT’D)

DEDUCTIBLE MET (MAABD or MAF)

A5	You met all eligibility requirements when you met your deductible. (Section 2304 and 2360 of the Aged, Blind, and Disabled Manual, or Section 3215 and 3315 of the Family and Children's Manual.)
A8	You met all eligibility requirements when you met your deductible. Medicaid benefits for all others on the application have been approved in another case. (Section 3215 and 3315 of the Family and Children's Manual.)
A9	You met all eligibility requirements when you met your deductible. Medicaid benefits for all others on the application have been denied. (Section 3215 and 3315 of the Family and Children's Manual.)

RESERVE MET (MAABD, MAF, or MQB)

B1	You met all eligibility requirements when you met permitted reserve limits. (Section 2304 and 2230 of the Aged, Blind, and Disabled Manual or Section 3215 and 3320 of the Family and Children's Manual.)
B2	You met all eligibility requirements when you met permitted reserve limits. Medicaid benefits for all others on the application have been approved in another case. (Section 3215 and 3320 of the Family and Children's Manual.)
B3	You met all eligibility requirements when you met permitted reserve limits. Medicaid benefits for all others on the application have been denied. (Section 3215 and 3320 of the Family and Children's Manual.)

REISSUED 07/01/10 – CHANGE NO. 01-11

MA APPROVAL CODES (CONT’D)

LTC Sanction and Excess Equity Value (MAABD)

M1	Due to asset transfers and an imposed sanction period you are ineligible for Medicaid to pay for institutional services. Medicaid will pay for other covered services. (Section 2240 of the Aged, Blind, Disabled Manual.) Requires Notice Text be entered also. Refer to MA-2240 for notice text requirements.
M2	Due to a home with an equity value more than the allowed amount you are ineligible for Medicaid to pay for institutional services. Medicaid will pay for other covered services. (Section 2242 of the Aged, Blind, Disabled Manual.) Requires Notice Text be entered also. Refer to MA-2242 for notice text requirements.
M5	You have not provided the information needed to establish eligibility for institutional services. Medicaid will pay for other services. (Section 2240 or 2270 of the Aged, Blind, and Disabled Manual)

WORK FIRST TERMINATED CASES REOPENED

B5	Medicaid has been reinstated because you/your family may not have been evaluated for Medicaid when Work First terminated. You will be notified by mail to complete a redetermination for continued eligibility.

ADD-INDIVIDUALS AND AUTOMATIC NEWBORN COVERAGE - NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

Application Type 3 (Automatic Newborn)

A3	This individual(s) meets all eligibility requirements. (Section 3215 and 3230 of the Family and Children's Manual.)

Application Type 6 (Other Add-Ons)

A6	This individual(s) meets all eligibility requirements. (Section 3215 and 3230 of the Family and Children's Manual.)

Application Type 7 (Automatic Newborn)

A7	The individual for whom you applied meets all eligibility requirements. Medicaid will continue through the month the child becomes age 1 if the child remains in your care. (Sections 3215 and 3230 of the Family and Children's Manual.)

REVISED 07/01/10 – CHANGE NO. 01-11

MA APPROVAL CODES

MPW AND PRESUMPTIVE ELIGIBILITY CODES

Approval of Presumptive and MPW Coverage

P1	You meet eligibility requirements for all pregnancy related services including labor and delivery. (Section 3240 of the Family and Children's Manual.)

Approval of MPW with no Presumptive Coverage

P5	You meet eligibility requirements for all pregnancy related services including labor and delivery. (Section 3240 of the Family and Children's Manual.)

ADD-INDIVIDUALS AND AUTOMATIC NEWBORN COVERAGE APPROVAL CODES (CONT’D)

Approval of Presumptive Only

P6	You are covered for ambulatory pregnancy related services, but not for labor, delivery, or other inpatient services. (Section 3245 of the Family and Children's Manual.)

SECONDARY NOTICE CODE - NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

A SECONDARY NOTICE CODE MAY BE USED IN CONJUNCTION WITH THE APPROVAL NOTICE CODE. HOWEVER, YOU MAY NOT USE THE SECONDARY NOTICE CODE IF YOU USE THE NOTICE TEXT FIELD.

B8	The following individual is approved for Medicaid for the months of ______thru ______. You must provide verification of citizenship and/or identity to continue to receive Medicaid. If documentation is not received, your Medicaid will be terminated.
C1	The other part of your application is still pending.
C2	Your eligibility for full Medicaid is still pending.
C3	The other month(s) for which you applied were denied because you did not meet your deductible.
C4	The other month(s) for which you applied were denied because you did not have a medical need.

REISSUED 07/01/10 – CHANGE NO. 01-11

MA APPROVAL CODES (CONT’D)

SECONDARY NOTICE CODE - NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

C5	The other date(s) for which you applied were denied because your reserve exceeded the limit.
C6	The other month(s) for which you applied were denied because you were not a resident of North Carolina.
C7	The other dates for which you applied were denied because you did not have a medical emergency on those dates.
C8	The other month(s) for which you applied were denied because you did not have a child in the home.
C9	The other month(s) for which you applied was/were denied because you were receiving in another state.

NOTICE TEXT FIELDS

The Notice Text field may be used in conjunction with the Approval Code to provide additional information to the applicant. However, you may not use the Notice Text if you use the Secondary Notice Code.

The Notice Text field allows free-form entry of information that is not tabled in any code. The Notice Text field has three lines with 72 characters per line.

The Notice Text field is not allowed for M-IC cases.

REISSUED 03/01/010 – CHANGE NO. 03-10

DISPOSITION CODES - MEDICAL ASSISTANCE DENIALS(G8 IS THE ONLY DENIAL CODE FOR M-SB CASES.)

NOTE: DO NOT USE THESE CODES FOR NC HEALTH CHOICE. NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

1. The reason code entered as the application disposition reason will determine the text to be printed on the automated DSS-8109.

2. For Medicaid denials, the text will be:

“This is to notify you that your application for Medicaid has been denied.”

3. Followed by:

“The reason for this action is:

_________________________________________”

4. “The state regulations applied to make this decision are found in Section _______ of the MA Manual.”

RESERVE REQUIREMENTS

A1	Your reserve is greater than the permitted limits. (Not applicable to M-SB, M-PW, M-IC). Sections 2000, 2230, 3230, 3320

LTC – (MAA, MAB, and MAD only)

A4	Due to asset transfers and an imposed sanction period you are ineligible for all Medicaid services. Manual notice required.
A5	Due to asset transfers and an imposed sanction period you are ineligible for institutional services. As a result you are also ineligible for other Medicaid services because of excess resources. Manual notice required.
A6	Due to asset transfers and an imposed sanction period you are ineligible for institutional services. As a result you are also ineligible for other Medicaid services because of excess income. Manual notice required.
P1	Due to asset transfers, you are ineligible for Medicaid to pay for PACE services. You are also ineligible for other Medicaid services because you are enrolled in the PACE Program. Manual notice required.

REVISED 03/01/10 – CHANGE NO. 03-10

MA INCOME REQUIREMENTS DENIAL CODES (CONT’D)

INCOME REQUIREMENTS - NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

B1	Your income is more than the allowed amount to receive Medicaid. Sections 2000, 2260, 3230, 3305
B2	Your medical expenses do not indicate you will meet your deductible within your certification period. If your medical expenses increase, reapply. (Not applicable to M-QB, M-PW, M-IC or I-AS.) Sections 2260, 2304, 3305, 3215
B4	There is no medical need in the retro months for the individuals for whom you applied. Valid for all Aid Program/Categories. Sections MA 3230, 3235

RESIDENCE REQUIREMENTS - NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

C1	You do not meet the state residence requirement. Sections 2000, 2220, 3230, 3335
C5	You are living in a public non-medical institution. (Not applicable to M-QB) Sections 2000, 3230, 3240(MPW)
G3	You have moved to another state. Sections 2000, 2220, 3230, 3335

CITIZENSHIP/ALIEN STATUS REQUIREMENTS - NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

C2	You are not a U.S. citizen, refugee, or Qualified Alien. Sections 2000, 2504, 3230, 3330
G4	We are unable to document your Alien status. Sections 2000, 2504, 3230, 3330
H9	You have not provided necessary information to document citizenship and/or identity. Sections 2304 or 3215
N1	You did not provide documentation of citizenship and/or identity (Individual(s) previously received benefits while trying to resolve citizenship code “97”). Section 2505/3331

REVISED 03/01/10 – CHANGE NO. 03-10

MA DENIAL CODES (CONT’D)

AGE REQUIREMENTS - NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

C3	You do not meet age requirements. (Not applicable to M-AB, M-QB, M-PW). Sections 2000, 2500, 3230, 3345

DISABILITY REQUIREMENTS

D1	Your condition does not meet the State or the SSI definition of disability/blindness. (M-AD and M-AB only). Section 2000, 2525
M3	You did not assist in determining your disability (MAD only). Sections 2304, 2525

HCWD (HEALTH COVERAGE FOR WORKERS WITH DISABILITIES)

H1	You did not pay the (HCWD) Health Coverage for Workers with Disability enrollment fee. (MAD and MAB only). Section 2180 of the Aged, Blind, and Disabled Medicaid Manual.

HSF/IAS

L0 Numeric Zero

You do not meet the requirements for the Expanded Foster Care Program. Section 3230 of the Family and Children’s Medicaid Manual.

MQB-E

E1	Funding is no longer available for this program for this calendar year. Section 2160
E2	Funding for this program ends on December 31st each year. Section 2160

MAF

M8	There are no children age 18 or under living in your care or in your household. Section 3235
M9	There are no children age 18 or under living in your care or in your household to whom you are related. Section MA 3350

REISSUED 03/01/10 - CHANGE NO. 03-10

MA OTHER REQUIREMENTS DENIAL CODES - NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

C6	You are not entitled to Medicare “A”. (M-QB ONLY) Section 2140, 2160
C8	You did not cooperate with the child support agency in establishing support for a child who receives Medicaid. Section 3235 and 3365
C9	You did not have a medical emergency. Section 2504 or 3330
D3	You have not provided verification of pregnancy. (M-PW, M-AF ONLY) Section 3240
D7	You are not the primary caregiver of a child due to joint custody. Therefore, you are ineligible for Medicaid. Section 3235 (M-AF, M-IC)
D8	You have Medicare or other comprehensive Health Insurance. Section 3250
F1	We have been unable to locate you by letter or by phone. Sections 2304 or 3215
F2	You are already receiving assistance in another case. Sections 2000, 3230, 3240 (MPW)
F3	You have refused to allow us to match your social security number against other agencies' records. Sections 2304, 2430, 3215, 3515
F5	You have been approved to receive benefits in another aid program category. Sections 2000, 2304, 3215, 3230
F6	Eligibility does not exist due to the death of the applicant or a child. (Manual Notice Required)
F8	You do not qualify for Family Planning Waiver services. Section 3265
F9	You are eligible for the Family Planning Waiver, but the program enrollment limit has been reached. When an opening is available, you will be contacted. (MAF-D only for capped enrollment)

REISSUED 03/01/10 - CHANGE NO. 03-10

MA OTHER REQUIREMENTS DENIAL CODES (CONT.)

G1	You have not provided the information needed to establish eligibility. Section 2304 or 3215
G6	You refused to provide or apply for a social security number. Sections 2304, 2450, 3215, 3355
G8	Administrative Denial (No manual notice required unless indicated)
G9	Other (Manual Notice Required) (N/A to M-IC.)
K9	You did not keep your appointments for your interview. Sections 2304, 3215

REISSUED 03/01/10 – CHANGE NO. 03-10

DISPOSITION CODES – MEDICAL ASSISTANCE WITHDRAWALS

NOTE: DO NOT USE THESE CODES FOR NC HEALTH CHOICE. NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

1. The reason code entered as the application disposition reason will determine the text to be printed on the automated DSS-8109.

2. For Medicaid applications, the text will be:

“This is to notify you that your application for ________ has been withdrawn.”

3. Followed by:

“The reason for this action is:

_________________________________________”

4. “The state regulations applied to make this decision are found in Section _______ of the Medicaid Manual.”

W1	You asked that your application be withdrawn. Sections 2304, 3215
W2	You asked that your application be withdrawn rather than comply with child support requirements. (Not applicable to M-SB or MQB-E). Sections 2304, 2375, 3215, 3365
W5	You asked that your application be withdrawn rather than allow us to match your social security number against other agencies’ records. Sections 2304, 2430, 3215, 3515

REISSUED 03/01/10 – CHANGE NO. 03-10

MEDICAID TERMINATION CODES

NOTE: DO NOT USE THESE CODES FOR NC HEALTH CHOICE. NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

DSS-8110A

Based on the “ADEQUATE” or “TIMELY” termination code entered on the DSS-8125, EIS will produce a notice to say:

1. “Adequate” or “Timely” is indicated at the top of the notice.

2. The Change Which Will Take Place:

“Effective MMDDCCYY

All Medicaid Benefits Will Stop.”

If Medicare B was coded “Y”:

“Medicaid will stop paying your Medicare Part B premium.”

3. Why The Change Will Be Made:

A reason that will correspond to one of the reasons listed below. Then the sentence:

“State rules supporting this action are found in Section _______ of the _______Manual.”

The appropriate section from the corresponding manual will be inserted. Based on the aid program/category, the manual title will be the Aged, Blind, and Disabled Medicaid Manual or the Family and Children’s Medicaid Manual. If and individual (s) becomes ineligible for Medicaid, do not throw away the card. The individual may become eligible again and will need the card.

4. When The Change Will Be Made:

a. If the termination code entered is an “ADEQUATE” code, the notice will state:

“The change is effective on MMDDCCYY.”

b. If the termination code entered is a “TIMELY” code, the notice will state:

“The change will be effective on MMDDCCYY, which is 10 workdays from the date of this letter, unless you ask for a hearing on or before that date.”

REISSUED 03/01/10 – CHANGE NO. 03-10

MA TERMINATION CODES (CONT’D) – NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

AGE

REASON	TIMELY	ADEQUATE
The only eligible child no longer meets age requirements. (Section 3230 of the Family and Children’s Manual.)	22	77

CARETAKER ONLY

REASON	TIMELY	ADEQUATE
There are no children age 18 or under living with you. (Section 3230 of the Family and Children’s Manual.)	23	57
You are no longer eligible because you did not cooperate with the child support agency in establishing support for a child who receives Medicaid. (Sections 2000 and 2375 of the Aged, Blind, and Disabled Manual or Sections 3235 and 3365 of the Family and Children's Manual.)	24	6I

DEDUCTIBLE

REASON	TIMELY	ADEQUATE
You did not meet your deductible and there is no indication you can meet a deductible in the next certification period. (Sections 2350 and 2360 of the Aged, Blind, and Disabled Manual or Sections 3425 and 3315 of the Family and Children’s Manual.)	04	73
There is no indication you can meet a deductible in the next certification period. (Sections 2350 and 2360 of the Aged, Blind, and Disabled Manual or Sections 3315 and 3425 of the Family and Children’s Manual.)	28	84

REVISED 03/01/10 – CHANGE NO. 03-10

MA TERMINATION CODES (CONT’D) - NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

DETERMINATION OF ELIGIBILITY

REASON	TIMELY	ADEQUATE
You have failed to complete a redetermination of eligibility. (Section 2320 of the Aged, Blind, and Disabled Manual or Section 3420 of the Family and Children’s Medicaid Manual.)	13	78
You have failed to provide wage information which is needed to determine eligibility. (Section 2000 of the Aged, Blind, and Disabled Manual or Section 3230 of the Family and Children’s Medicaid Manual.)	14	79
You have failed to provide a social security number which is needed to determine eligibility. (MIC and MPW only) (Sections 3420 and 3355 of the Family and Children’s Medicaid Manual.)	15	81
You did not provide the necessary information to determine your eligibility. (Section 2320 of the Aged, Blind, and Disabled Manual or Section 3420 of the Family and Children’s Manual.)	20	72
You have failed to cooperate in determining the amount of unemployment benefits you are potentially eligible to receive. (MAF only) (Sections 3300 and 3230 of the Family and Children’s Manual.)	27	83
You have not provided necessary information to document citizenship and/or identity. (Section 2304 of the Aged, Blind, and Disabled Manual or Section 3215 of the Family and Children’s Manual.)	2Q	6Q
You have failed to provide documentation of citizenship and/or identity (Individual(s) previously received benefits while trying to resolve citizenship code “97”). (Section 2505/3331.)	2R	6R

REISSUED 03/01/10 – CHANGE NO. 03-10

MA TERMINATION CODES (CONT’D) NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

DISABILITY

REASON	TIMELY	ADEQUATE
You no longer meet disability rules. (Section 2000 of the Aged, Blind, and Disabled Manual.) (Not applicable to MQB.)	06	6F
You did not provide medical information to verify continuing disability. (Section 2000 of the Aged, Blind, and Disabled Manual.)	07	6G

HCWD HEALTH COVERAGE FOR WORKERS WITH DISABILITIES

You did not pay the Enrollment fee for (HCWD) Health Coverage for Workers with Disabilities. (Section 2180 of the Aged, Blind, and Disabled Manual.) Suspended Effective 12/1/09

2H

7H

INCOME, NEEDS

REASON	TIMELY	ADEQUATE
Your income exceeds the income limit. (MQB,MAF, and MIC only) (Sections 2000 and 2260 of the Aged, Blind, and Disabled Manual or Sections 3230 and 3305 of the Family and Children’s Manual.)	09	74
Your income exceeds the income limit. (MIC – To be used during NCHC enrollment freeze.) (Sections 3230 and 3305 of the Family and Children’s Manual.)	1E	6E

MAF – BREAST AND CERVICAL CANCER MEDICAID (BCCM)

REASON	TIMELY	ADEQUATE
You are no longer eligible for Breast and Cervical Cancer coverage. (Section 3250 of the Family and Children’s Medicaid Manual.)	2B	6B
You do not meet age requirements for Breast and Cervical Cancer coverage. (Section 3250 of the Family and Children’s Medicaid Manual.)	2C	6C
You obtained Health Insurance or Medicare and are no longer eligible for Breast and Cervical Cancer coverage. (Section 3250 of the Family and Children’s Medicaid Manual.)	2D	6D

REISSUED 03/01/10 – CHANGE NO. 03-10

MA TERMINATION CODES (CONT’D) NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

HSF and IAS

REASON	TIMELY	ADEQUATE
You do not meet the requirements for the Expanded Foster Care Program (Section 3230 of the Family and Children’s Medicaid Manual.)	1O Alpha O	6O Alpha O

MAF-D FAMILY PLANNING

REASON	TIMELY	ADEQUATE
You do not qualify for Family Planning Waiver services. (Section 3265 of the Family and Children’s Medicaid Manual.)	1L	6L
You are eligible for the Family Planning Waiver, however, the number that can receive Family Planning Waiver services has been reached. (Section 3265 of the Family and Children’s Medicaid Manual.) (MAF-D only for capped enrollment)	1M	6M

MQB-E

REASON	TIMELY	ADEQUATE
Funding for this program ends on December 31st each year. (Section 2160 of the Aged, Blind, and Disabled Manual.)	N/A	65

PRESUMPTIVE ELIGIBILITY AND MPW

REASON	TIMELY	ADEQUATE
You did not make an application for Medicaid. (Presumptive eligibility only) (Sections 3240 and 3245 of the Family and Children's Manual.)	N/A	60
You do not meet eligibility requirements. (Presumptive eligibility only) (Sections 3240 and 3245 of the Family and Children's Manual.)	N/A	61

REISSUED 03/01/10 – CHANGE NO. 03-10

MA TERMINATION CODES (CONT’D) NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

PRESUMPTIVE ELIGIBILITY AND MPW

REASON	TIMELY	ADEQUATE
You are no longer pregnant and you are not eligible for any other Medicaid coverage. (MAF and MPW) (Sections 3230 and 3240 of the Family and Children's Manual.)	1F	62

REQUESTED

REASON	TIMELY	ADEQUATE
You asked in writing that your Medicaid be stopped. (Section 2000 of the Aged, Blind, and Disabled Manual or Section 3230 of the Family and Children’s Manual.)	N/A	55
You asked that your Medicaid be stopped because you did not want your social security number matched with federal records. (Section 2000 of the Aged, Blind, and Disabled Manual or Section 3230 of the Family and Children’s Manual.)	N/A	56
You asked that your Medicaid be stopped. (Verbal) (Section 2000 of the Aged, Blind, and Disabled Manual or Section 3230 of the Family and Children's Manual.)	29	6K

RESERVE

REASON	TIMELY	ADEQUATE
Your total countable resources exceed the Medicaid limit. (Sections 2230 and 2260 of the Aged, Blind, and Disabled Manual or Sections 3230 and 3320 of the Family and Children’s Manual.)	05	71

REISSUED 03/01/10 – CHANGE NO. 03-10

MA TERMINATION CODES (CONT’D) NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

RESIDENCE

REASON	TIMELY	ADEQUATE
You have moved out of North Carolina. (Section 2000 of the Aged, Blind, and Disabled Manual or Section 3230 of the Family and Children’s Manual.)	1D	6H
You have moved out of North Carolina and you are receiving Medicaid from another state. (Section 2000 of the Aged, Blind, and Disabled Manual or Section 3230 of the Family and Children’s Manual.)	N/A	53
We are unable to locate you. (Section 2352 of the Aged, Blind, and Disabled Manual or Section 3410 of the Family and Children’s Manual.)	21	63
You cannot get Medicaid in your current living arrangement. (Section 2510 of the Aged, Blind, and Disabled Manual or Section 3360 of the Family and Children’s Manual.)	N/A	64

OTHER

REASON	TIMELY	ADEQUATE
The recipient is deceased. (Section 2000 of the Aged, Blind, and Disabled Manual or Section 3230 of the Family and Children’s Manual.)	N/A	52
Your Medicaid continues in another case. (Section 2000 of the Aged, Blind, and Disabled Manual or Section 3230 of the Family and Children’s Manual.)	N/A	54
There was a change in law or agency policy of which you were previously notified. (Section 2000 of the Aged, Blind, and Disabled Manual or Section 3230 of the Family and Children’s Manual.)	N/A	58

REISSUED 03/01/10 – CHANGE NO. 03-10

MA TERMINATION OTHER CODES (CONT’D) NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

REASON	TIMELY	ADEQUATE
You only applied for the dates specified above. (Section 2301 and 2304 of the Aged, Blind, and Disabled Manual or Section 3205 and 3215 of the Family and Children’s Manual.)	N/A	59
You refused to allow your social security number to be matched with federal records. (Section 2000 of the Aged, Blind, and Disabled Manual or Section 3230 of the Family and Children's Manual.)	25	6J
Due to asset transfers, you are ineligible for Medicaid to pay for PACE services. You are also ineligible for other Medicaid services because you are enrolled in the PACE program. (Manual notice required).	2P	7P
Other: Use Notice Text to enter the appropriate text. You are limited to three lines with 72 characters per line in using the Notice Text field. You must enter a manual citation. (N/A to M-IC)	02	50
Other: Adequate (Manual Notice Required). (N/A to M-IC)	N/A	70

AUTOMATIC EIS TERMINATIONS (SYSTEM ASSIGNED - DO NOT ENTER)

REASON	TIMELY	ADEQUATE
Aid program/category transfer	N/A	67
County reassignment	N/A	68
You have failed to complete a redetermination of eligibility. (MIC) System Generated. (Section 3420 of the Family and Children’s Manual.)	N/A	80
Other: System generated termination.	N/A	90
MQB-E: (System Generated.) You have failed to complete a redetermination of eligibility. (Section 2160 of Aged, Blind and Disabled Medicaid Manual.)	N/A	92

REISSUED 03/01/10 – CHANGE NO. 03-10

TRANSFERS (AID PROGRAM/CATEGORY)

Transfers to and from MRF, RRF, SAD, SAA, or SCD will not generate an automated notice. A change code is not required for these transfers. MAD to MAA does not require a notice.

NOTE: DO NOT USE THESE CODES FOR NC HEALTH CHOICE. NC HEALTH CHOICE CODES ARE LOCATED IN EIS 4300 PART SIX.

I. TRANSFER notice requirements

A. The following transfers require ADEQUATE notice:

1. MQB to MAA, MAD, or MAB in “A” status

2. MAF to MIC

3. MIC to MAF in “A” status

4. MAA or MAD in “D” status to MQB

5. AAF to MAF, MIC, or MPW Continuation

6. MAD to HSF (only allowed if the case is SSI)

7. HSF to MAD (only allowed if the case is SSI)

8. MQB to PACE (MAABD) in “A” status

B. The following transfers require TIMELY notice:

1. AAF to MAF

2. AAF to MIC

3. AAF to MPW

4. MAA, MAD, or MAB in “A” status to MQB

5. MAF to MPW

6. MIC to MAF in “D” status

7. MQB to MAA, MAD, or MAB in “D” status

REISSUED 03/01/10 – CHANGE NO. 03-10

II. Notice text

Based on the “Adequate” or “Timely” change code entered on the DSS-8125, EIS produces a notice to say:

A. “ADEQUATE” or “TIMELY” is indicated at the top of the notice.

B. “THE CHANGE WHICH WILL TAKE PLACE:”

“Effective MMDDCCYY”

“Your payment will be stopped. [if applicable]”

“Your Medicaid continues under another category."

“You are eligible for Medicaid for the following months:” MM/DD/CCYY – MM/DD/CCYY

1. If Medicaid Classification changes to “Q”, the following will print.

“Medicaid will pay your Medicare premiums.”

2. If the program changes from MAABD to MQB AND the Medicaid classification changes to “B” or “E”, the following will print:

“You will not receive a Medicaid card, however Medicaid will continue to pay your Medicare Part B premium.”

3. If the program changes to MQB AND the Medicaid classification changes from “Q” to “B” or “E”, the following will print:

“You will not receive a Medicaid card, however Medicaid will continue to pay your Medicare Part B premium.”

4. If the program changes to MAABD AND the case is authorized AND the Medicaid classification changes from “Q” to “M”, the following will print:

“Medicaid will stop paying your Medicare Part A premium. Medicaid will continue to pay your Medicare Part B premium.”

REISSUED 03/01/10 – CHANGE NO. 03-10

II.B. (CONT’D)

5. If Medicaid status is “D”, the following will print:

“You will not receive another Medicaid card until you meet your deductible for the following months:”

“MM/DD/CCYY thru MM/DD/CCYY $_____ is your Medicaid deductible.”

6. If a PML is entered, the following will print:

“$_____ is your monthly liability.”

“You must pay your liability to the nursing home each month.”

7. If Medicaid classification changes to “Q”, the following will print:

“Medicaid will pay your Medicare premiums.”

C. “WHY THE CHANGE WILL BE MADE:”

A reason that will correspond to the Change Code keyed will print followed by the sentence:

“State rules supporting this action are found in Section _________ of the __________ Manual.”

The appropriate section from the corresponding manual will be inserted. Based on the aid program/category, the manual title will be the Aged, Blind, and Disabled Medicaid Manual or the Family and Children's Medicaid Manual.

4. “WHEN THE CHANGE WILL BE MADE:”

a. If the change code entered is an “ADEQUATE” code, the notice will state;

“The change is effective on MM/DD/CCYY.”

b. If the change code entered is a “Timely” code, the notice will state;

“The change will be effective on MM/DD/CCYY, which is 10 workdays from the date of this letter, unless you ask for a hearing on or before that date.”

REISSUED 03/01/10 – CHANGE NO. 03-10

II.C. (CONT’D)

AAF to MAF

REASON	TIMELY	ADEQUATE
You refused to be screened for substance abuse. (Work First Manual)	1A	5A
You failed to register with the Employment Security Commission for First Stop. (Work First Manual)	1B	6B
The only individual in the case has been convicted of a drug felony. (Work First Manual)	1D	7C
The only individual in the case misrepresented his residence. (Work First Manual)	1E	7D
The only individual in the case is a fleeing felon. (Work First Manual)	1F	7E
The only individual in the case violated the conditions of his parole or probation.(Work First Manual)	1G	7F
You did not help in determining the amount of Unemployment Benefits you might have been able to receive. (Work First Manual)	1H	7G
You did not request Work First Family Assistance for someone who is required to be included in your case. (Work First Manual)	1I	7H
You did not register for First Stop at the Employment Security Commission. We are continuing to determine your Medicaid Eligibility. (Work First Manual)	1Z	7Z
You failed to sign your mutual responsibility agreement. (Work First Manual)	2A	7A
Your Work First Family Assistance is stopping because you do not qualify for at least the minimum payment. However, you will continue to receive Medicaid as long as you are eligible. (Work First Manual)	2K	6K
A family member has been disqualified because of an intentional program violation. He/She remains eligible for Medicaid. (Work First Manual)	2Z	5W

REISSUED 03/01/10 – CHANGE NO. 03-10

II.A. (AAF to MAF CONT’D)

REASON	TIMELY	ADEQUATE
You have moved to another county. Your Work First Benefit does not transfer. If you wish to continue receiving a check, you need to apply in the new county. (Work First Manual)	27	6C
Because of the new Work First policy, relatives other than parents or stepparents can not be included in the Work First Benefit. (Work First Manual)	28	6D
The only child you were receiving Work First Family Assistance for is age 18 and will not finish high school by age 19. (Work First Manual)	29	6E
Your family’s benefit diversion certification period has ended. (Work First Manual)	N/A	87
You did not apply for other benefits which you might be eligible to receive. (NOTE: Do not use for UIB) (Work First Manual)	3o	9o
You did not complete your rehab program, therefore you are no longer eligible for a Work First check. (Work First Manual)	3R	9R
You failed to meet the requirements of your MRA and will no longer receive Work First Benefits. Your Medicaid will continue. (Work First Manual)	N/A	83
You failed to comply with Sanction requirements. Your payment will be stopped. Your Medicaid will continue under another category. (Work First Manual)	N/A	6U
You failed to complete work activities listed on the MRA. (Payment Type ‘2’ to MAFC and can be either worker entry or system generated.)	N/A	5T
You failed to cooperate with substance abuse treatment. (Payment Type ‘2’ to MAFC and can be either worker entry or system generated.)	N/A	9A

REISSUED 03/01/10 – CHANGE NO. 03-10

AAF TO MAF, MIC, OR MPW

REASON	TIMELY	ADEQUATE
You failed to provide information which is needed to determine eligibility.(Work First Manual)	1W	6A
Your family's total income is too high for your family to receive Work First Family Assistance. (Work First Manual)	19	65
Your family’s income is too high for you (your family) to get Work First Family Assistance. (Work First Manual)	20	66
Your family's projected income is too high for you to receive Work First Family Assistance. (Work First Manual)	34	94
You no longer meet reserve limits for Work First Family Assistance. (Work First Manual)	39	85
You requested your Work First check be stopped. (Work First Manual)	3M	9M
There is no longer a child in your home who is eligible to receive Work First Family Assistance. (Work First Manual)	3N	9N
There is no caretaker for this Work First Family Assistance case. (Work First Manual)	3Q	9Q
You have now had your baby. You must apply for Work First for the baby within 10 days. (Work First Manual)	3S	6S
Your earned income is too high for you (your family) to get Work First Family Assistance based on verified earned income data. Your eligibility for Medicaid is being evaluated. (Note: Use these codes only when it relates to “New Hire” data). Work First Manual	1P	6V

REISSUED 03/01/10 – CHANGE NO. 03-10

II.A. (AAF to MAF, MIC, OR MPW CONT’D)

Your unearned income is too high for you (your family) to get Work First Family Assistance based on verified unemployment data. Your eligibility for Medicaid is being evaluated. (Note: Use these codes only when it relates to “New Hire” data). Work First Manual	24	7B
You failed to provide information regarding employment which is needed to determine eligibility. Your eligibility for Medicaid is being evaluated. (Note: Use these codes only when it relates to “New Hire” data). Work First Manual	26	7Y
You failed to provide information regarding unemployment benefits which is needed to determine eligibility. Your eligibility for Medicaid is being evaluated. (Note: Use these codes only when it relates to “New Hire” data). Work First Manual	1C	6F

The following two codes can be either system generated or worker initiated. If system-generated, the worker number will be ‘EIS’.

REASON	TIMELY	ADEQUATE
Your family has reached your 24 month Work First time limit. Contact your local social services to request an extension if you believe you have a good cause reason to receive additional months of benefits. (Work First Manual)	N/A	88
Your family has reached your 60 month Work First time limit. Contact your local social services to request an extension if you believe you have a good cause reason to receive additional months of benefits. (Work First Manual)	N/A	89

AAF TO MAF – SYSTEM GENERATED

REASON	TIMELY	ADEQUATE
You failed to return your quarterly report by the established deadline. Your eligibility for Medicaid is being evaluated. You will receive a separate notice about Medicaid. (Work First Manual)	N/A	52

REISSUED 03/01/10 – CHANGE NO. 03-10

II. A. (CONT’D)

MQB to MAABD

REASON	TIMELY	ADEQUATE
You met your deductible. (Section 2340 and 2360 of the Aged, Blind, and Disabled Manual)	N/A	80

MQB to PACE (MAABD)

REASON	TIMELY	ADEQUATE
You are eligible for PACE. (Section 2275 of the Aged, Blind, and Disabled Manual)	N/A	8J

LTC (MQB to MAABD)

REASON	TIMELY	ADEQUATE
You entered a long term care facility. (Section 2270 of the Aged, Blind, and Disabled Manual)	N/A	74

MQB TO MAABD IN AUTHORIZED STATUS DUE TO REDUCTION IN INCOME

REASON	TIMELY	ADEQUATE
Your income has decreased. (Sections 2340 and 2250 of the Aged, Blind, and Disabled Manual)	N/A	84

MQB TO MAABD IN AUTHORIZED STATUS DUE TO REDUCTION IN RESERVE

REASON	TIMELY	ADEQUATE
The amount of your reserve is now below the allowable limit. (Sections 2230 and 2260 of the Aged, Blind, and Disabled Manual)	N/A	5Q

MQB TO MAABD IN DEDUCTIBLE STATUS

REASON	TIMELY	ADEQUATE
Your income exceeds the income level for Medicaid, causing you to have a deductible. Medicaid will continue to pay your Medicare Part B premium. (Sections 2000 and 2260 of the Aged, Blind, and Disabled Manual)	38	92

ISSUED 03/01/10 – CHANGE NO. 03-10

II. (CONT’D)

MAABD IN “D” STATUS TO MQB

REASON	TIMELY	ADEQUATE
You continue to have to meet a deductible to be eligible for full Medicaid, because your income exceeds the income limit. Medicaid will pay your Medicare Part B premium. (Sections 2000 and 2260 of the Aged, Blind, and Disabled Manual)	N/A	6J

MAABD IN “A” STATUS TO MQB-Q

REASON	TIMELY	ADEQUATE
Your resources exceed the Medicaid limit. Medicaid will continue to pay your Medicare Part B premium. (Sections 2230 and 2260 of the Aged, Blind, and Disabled Manual)	35	91

MAABD IN “A” STATUS TO MQB-B/E

REASON	TIMELY	ADEQUATE
Your income exceeds the income limit. Your Medicaid card will stop. The state will continue to pay your Medicare Part B premium only. (Sections 2140 and 2160 of the Aged, Blind, and Disabled Medicaid Manual)	25	93

MIC TO MAF IN “A” STATUS

REASON	TIMELY	ADEQUATE
You meet eligibility requirements for a new Medicaid category. (Section 3230 of the Family and Children's Manual)	N/A	82

MIC TO MAF IN “D” STATUS

REASON	TIMELY	ADEQUATE
Your income is over the income limit for full Medicaid coverage causing you to have a deductible. (Section 3305 of the Family and Children’s Manual)	37	97

REISSUED 02/01/11 – CHANGE NO. 03-11

II. (CONT’D)

MPW TO MAF IN “A” STATUS

REASON	TIMELY	ADEQUATE
You now qualify for full Medicaid coverage. (Section 3305 of the Family and Children's Manual)	N/A	69

MPW TO MAF IN “D” STATUS

REASON	TIMELY	ADEQUATE
Your pregnancy has ended. You now must meet a deductible. (Sections 3240 and 3305 of the Family and Children’s Manual)	2L	7L

MPW TO MAF-D

REASON	TIMELY	ADEQUATE
You no longer meet the eligibility requirements for pregnancy services. However, you are eligible for Family Planning Waiver services. (Section 3265 of the Family and Children’s Medicaid Manual)	1N	5N

MAF TO MPW

REASON	TIMELY	ADEQUATE
You no longer meet the eligibility requirements for full Medicaid. You are eligible for Medicaid as a pregnant woman. (Section 3240 of the Family and Children's Manual)	36	5P

MAF-D TO MPW

REASON	TIMELY	ADEQUATE
You no longer meet the eligibility requirements for Family Planning Medicaid. You are eligible for Medicaid as a pregnant woman. (Section 3240 of the Family and Children's Manual)	N/A	6R

REVISED 02/01/11 – CHANGE NO. 03-11

II. (CONT’D)

MAF TO MIC

REASON	TIMELY	ADEQUATE
You no longer meet the income limits for MAF; however, your child(ren) is eligible for MIC. (Section 3305 of the Family and Children’s Manual)	23	81

SUSPENSION DUE TO INCARCERATION OR IN AN IMD

REASON	TIMELY	ADEQUATE
Your Medicaid will be suspended because you are incarcerated. Your Medicaid coverage is limited to payment of medical services related to an inpatient hospital stay. No card will be issued. (DMA Administrative Letter No. 09-08)	N/A	78
Your Medicaid will be suspended because you are in an Institution for Mental Diseases. You will not have any Medicaid coverage during the suspension. No card will be issued. (DMA Administrative Letter No. 09-08)	N/A	98

OTHER

REASON	TIMELY	ADEQUATE
You no longer meet the eligibility requirements for full Medicaid. However, you are eligible for Family Planning Waiver services. (MAF-D Only) (Section 3265 of the Family and Children’s Medicaid Manual)	1T	6Q
MANUAL NOTICE REQUIRED (N/A to MIC)	45	90
Other: Use Notice Text to enter the appropriate text. You are limited to three lines with 72 characters per line when using Notice Text field. You must enter a manual reference if you use this code. (N/A to MIC).	02 Numeric Zero	50 Numeric Zero