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NC DEPARTMENT OF HEALTH AND HUMAN SERVICES EIS MANUAL
ELIGIBILITY INFORMATION SYSTEM EIS 4000
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CODES APPENDIX D – SPECIAL ASSISTANCE CODES
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CHANGE CODES - ADEQUATE SPECIAL ASSISTANCE CHANGES
REISSUED 01/01/06 - CHANGE NO. 03-06
Based on the adequate change code entered on the DSS-8125, EIS will produce a notice to say:
$______ This is your increased payment amount.
MMYY This is the date your monthly payment begins.
Medicaid continues.
$______ This is your increased payment amount.
MMYY This is the date your monthly payment begins.
When an individual termination date or date of death is present:
(Name of individual) This individual(s) was deleted because of death or this individual(s) was terminated from your case.
$______ This is your increased payment amount.
MMYY This is the date your monthly payment begins.
$______ This is your reduced payment amount.
MMYY This is the date your monthly payment begins.
Medicaid continues.
REVISED 01/01/06 - CHANGE NO. 03-06
SA ADEQUATE CHANGE NOTICE TEXT (CONT'D)
$______ This is your reduced payment amount.
MMYY This is the date your monthly payment begins.
When an individual termination date or date of death is present:
(Name of Individual) This individual(s) was deleted because of death or this individual(s) was terminated from your case.
$______ This is your reduced payment amount.
MMYY This is the date your monthly payment begins.
MMDDCCYY Medicaid will pay your Medicare premiums.
“Now that you are enrolled/receiving Medicare, Medicaid will not pay for your prescriptions. Medicare is responsible for your prescriptions.”
"State rules supporting this action are found in Section _______ of the SA Manual."
REVISED 01/01/06 - CHANGE NO. 03-06
SA ADEQUATE CHANGE NOTICE TEXT (CONT'D)
INCOME
50 |
Notice Text - Do not enter. |
51 |
Your income has decreased. (Section 3210) |
52 |
Your spouse's income has decreased. (Section 3210) |
53 |
Your essential person's income has decreased. (SCD) (Section 3210) |
54 |
Your income has stopped. (Section 3210) |
55 |
Your spouse's income has stopped. (Section 3210) |
56 |
Your essential person's income has stopped. (SCD) (Section 3210) |
57 |
You have repaid the Special Assistance overpayment so no amount is being taken out of your check for that purpose. (Section 3300) |
58 |
The amount of the grant reduction that is being taken out of your Special Assistance payment has decreased. (Section 3300) |
59 |
You have requested by written statement that your assistance be reduced. (Section 3300) |
61 |
Your spouse no longer lives in your home and signed a statement asking to be removed from the SCD payment. (SCD) ( Appendix C) |
62 |
Your essential person signed a statement asking to be removed from the SCD payment. (SCD) ( Appendix C) |
REVISED 09/01/06 - CHANGE NO. 02-07
SA ADEQUATE CHANGE CODES (CONT'D)
63 |
Your spouse is now deceased and must be removed from the SCD payment. (SCD) ( Appendix C) |
64 |
Your essential person is now deceased and must be removed from the SCD payment. (SCD) ( Appendix C) |
65 |
Your ambulation capacity has changed from ambulatory to semi-ambulatory. (SAA and SAD) (Appendix D) |
66 |
Your spouse's monthly needs have increased. (SAA and SAD) (Section 3220) |
67 |
You are eligible for Medicare-Aid and Special Assistance. (Section 3310) |
68 |
Other (Manual Notice Required) |
6Z |
You have not provided necessary information to document citizenship and/or identity. (SCD) Section 3240) |
CAP CASES
When making changes to an SAA/SAD case with existing CAP Coverage, DO NOT enter a CHANGE CODE or NOTICE OVERRIDE. An automated notice is not produced. Complete a manual notice according to policy requirements.
DO NOT enter a CHANGE CODE or a NOTICE OVERRIDE when completing a DSS-8125 that contains only CAP information. An automated notice is not produced. Complete a manual notice according to policy requirements.
MEDICARE A AND/OR B INDICATOR CHANGE (SAA AND SAD)
Do not enter a change code when a DSS-8125 is keyed changing only the Medicare A and/or B indicator. If changing to an “N”, an adequate manual notice is required. If changing to a “Y”, a timely manual notice is required.
REISSUED 09/01/06 - CHANGE NO. 02-07
CHANGE CODES - TIMELY SPECIAL ASSISTANCE CHANGES
Based on the timely change code entered on the DSS-8125, EIS will produce a notice to say:
$______ This is your reduced payment amount.
MMYY This is the date your monthly payment begins.
Medicaid continues.
$______ This is your reduced payment amount.
MMYY This is the date your monthly payment begins.
When an individual termination date is present:
(Name of Individual) This individual(s) was deleted because of death or this individual(s) was terminated from your case.
$______ This is your reduced payment amount.
MMYY This is the date your monthly payment begins.
MMDDCCYY Medicaid will continue to pay your Medicare Part B premium.
“Now that you are enrolled/receiving Medicare, Medicaid will not pay your prescriptions. Medicare is responsible for your prescriptions.”
REVISED 09/01/06 - CHANGE NO. 02-07
SA TIMELY CHANGE CODES (CONT'D)
"State rules supporting this action are found in Section ________ of the SA Manual."
02 |
Notice Text - Do not enter |
INCOME
03 |
Your income has increased. (Section 3210) |
04 |
Your spouse's income has increased. (Section 3210) |
05 |
Your essential person's income has increased. (SCD) (Section 3210) |
OTHER FACTORS
06 |
An amount is being deducted from your Special Assistance payment to repay the amount of your previous Special Assistance overpayment. (Section 3300) |
07 |
The amount of the grant reduction that is being taken out of your Special Assistance payment has increased. (Section 3300) |
08 |
Your essential person asked to be removed from the SCD payment. (SCD) ( Appendix C) |
09 |
Your spouse no longer lives in your home and must be removed from the SCD payment. (SCD) ( Appendix C) |
10 |
Your essential person no longer lives in your home and must be removed from the SCD payment. (SCD) ( Appendix C) |
11 |
Your ambulatory capacity has changed from semi-ambulatory to ambulatory. (SAA and SAD) (Appendix D) |
12 |
Your spouse's monthly needs have decreased. (SAA and SAD) (Section 3220) |
14 |
You are no longer eligible for Medicare Aid. (Section 3310) |
3z |
You have not oprovided necessary information to document citizenship and/or identity. (SCD) (Section 3240) |
REVISED 01/01/06 - CHANGE NO. 03-06
SA TIMELY CHANGE CODES (CONT'D)
CAP CASES
When making changes to an SAA/SAD case with existing CAP Coverage, DO NOT enter a CHANGE CODE or NOTICE OVERRIDE. An automated notice is not produced. Complete a manual notice according to policy requirements.
DO NOT enter a CHANGE CODE or a NOTICE OVERRIDE when completing a DSS-8125 that contains only CAP information. An automated notice is not produced. Complete a manual notice according to policy requirements.
MEDICARE A AND/OR B INDICATOR CHANGE (SAA AND SAD)
Do not enter a change code when a DSS-8125 is keyed changing only the Medicare A and/or B indicator. If changing to a “Y”, a timely manual notice is required. If changing to an “N”, an adequate manual notice is required.
REISSUED 01/01/06 - CHANGE NO. 03-06
REDETERMINATION NOTICES WITH NO CHANGES IN THE CASE
DSS-8108A
Based on change code "01" entered on the DSS-8125, EIS will produce a notice to say:
$______ This is the payment you will continue to receive.
Medicaid continues.
$______ This is the payment you will continue to receive.
"State rules supporting this action are found in Section 3320 of the SA Manual."
CAP CASES
SAA/SAD Cases With Existing (Active) CAP Coverage
When completing a review for an SAA/SAD case with existing CAP Coverage, DO NOT enter a CHANGE CODE or NOTICE OVERRIDE. An automated notice is not produced. Complete a manual notice according to policy requirements.
REISSUED 03/01/10 - CHANGE NO. 03-10
DISPOSITION CODES - SPECIAL ASSISTANCE APPROVALS
ONGOING APPROVALS (APPLICATION TYPES 1, 2, AND 6)
"You will receive the following benefits for the months listed:
MMYY $_______
MMYY $_______
(Name of Individual and Individual ID Number)
$______ This is your monthly payment amount.
MMYY This is the date your monthly payment begins.
When RETRO MA1 is present the following text will be printed:
MMYY to MMYY This is additional Medicaid coverage you will receive.
MMDDYY This is the date your Medicaid coverage begins.
When Buy-In is present the following text will be printed:
MMDDYY The State will begin paying your Medicare Part B premium.
When a “Y” is keyed for Medicare A and/or B on the DSS-8125, the following sentence will be printed on the approval notice.
“If you receive Medicare, Medicare is responsible for your prescriptions.”
"You will receive the following benefits for the months listed:
MMYY $______
MMYY $______
$_____ This is your monthly payment amount.
MMYY This is the date your monthly payment begins.
REVISED 03/01/10 - CHANGE NO. 03-10
SA ONGOING APPROVALS (CONT'D)
A1 |
"Your application has been approved because you meet all eligibility requirements." (Section 3100) |
A2 |
"You are not eligible for the month of application because your assets exceed the reserve limit found in Section 3130 of the SA Manual. However, you have been approved for subsequent months because you meet all eligibility requirements." (Section 3100) |
A3 |
"You are not eligible for the month of application because your income was too high to receive SA. However, you have been approved for subsequent months because you meet all eligibility requirements." (Section 3100) |
A4 |
"You are not eligible for the month of application because you were not in a domiciliary care facility. However, you have been approved for subsequent months because you meet all eligibility requirements." (Section 3100) |
A5 |
"You are not eligible for the month of application because you lived or received assistance in another state. However, you have been approved for subsequent months because you meet all eligibility requirements." (Section 3100) |
A6 |
"Other" (Manual Notice Required) |
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 3245) |
CAP CASES
When completing a DSS-8125 to approve SAA or SAD with CAP Coverage, enter "Y" in the NOTICE OVERRIDE field. Complete a manual notice. If the NOTICE OVERRIDE field is blank, an automated notice will be produced; however, there will be no CAP information on the notice.
REVISED 10/01/09 - CHANGE NO. 01-10
SA APPROVALS (CONT'D)
OPEN/SHUT APPROVALS (APPLICATION TYPES 1, 2, AND 6)
"You will receive the following benefits for the months listed:"
MMYY $_____
MMYY $_____
(Name and Individual ID Number)
$______ This is your monthly payment amount.
MMYY This is the date your monthly payment begins.
When RETRO MA1 is present the following text will be printed:
MMYY to MMYY This is additional Medicaid coverage you will receive.
When Buy-In is present the following text will be printed:
MMDDYY The State will pay your Medicare Part B premium.
When the termination reason and date are present:
MMYY This is the last month you will receive a payment and Medicaid coverage or this is the last month you will receive a payment, Medicaid coverage, and your Medicare Part B premium paid by the State.
The termination reason entered determines the reason text printed.
When a “Y” is keyed for Medicare A and/or B on the DSS-8125, the following sentence will be printed on the approval notice.
“If you receive Medicare, Medicare is responsible for your prescriptions.”
REISSUED 10/01/09 - CHANGE NO. 01-10
SA OPEN/SHUT APPROVALS (CONT'D)
"You will receive the following benefits for the months listed:"
MMYY $_____
MMYY $_____
$_____ This is your monthly payment amount.
MMYY This is the date your monthly payment begins.
When the termination reason and date are present:
MMYY This is the last month you will receive a payment.
The termination reason entered determines the reason text printed.
OPEN/SHUT APPROVAL CODE AND TEXT
A7 |
"Your application has been approved because you meet all eligibility requirements." (Section 3100) |
CAP CASES
When completing a DSS-8125 to approve SAA or SAD with CAP Coverage, enter "Y" in the NOTICE OVERRIDE field. Complete a manual notice. If the NOTICE OVERRIDE field is blank, an automated notice will be produced; however, there will be no CAP information on the notice.
REISSUED 03/01/10 - CHANGE NO. 03-10
DISPOSITION CODES - SPECIAL ASSISTANCE DENIALS
"This is to notify you that your application for ______ has been denied.
"The reason for this action is: _____________________________________
RESIDENCE REQUIREMENTS
D2 |
You do not live in North Carolina. (Section 3250) |
G8 |
You are living in a public, non-medical institution. (Section 3100) |
G9 |
You are not living in a rest home or group home. Therefore, you are not eligible to receive Special Assistance. (Section 3100) |
H7 |
You moved to another state. (Section 3250) |
RESERVE REQUIREMENTS
G4 |
You and/or your spouse have cash, property, bank accounts, life insurance policies, and vehicles greater than allowed for you to receive Special Assistance. (Section 3200) |
M2 |
You sold, gave away, or assigned real property to someone else. (Manual Notice Required). (Section 3200) |
M3 |
You sold, gave away, or assigned personal property to someone else. (Manual Notice Required). (Section 3200) |
INCOME REQUIREMENTS
G5 |
You and/or your spouse have net income greater than allowed to receive Special Assistance. (Section 3100) |
DISABILITY REQUIREMENTS
H0 |
Your condition does not meet the State definition of disability/blindness. (SCD - Appendix C) |
H1 |
Your condition does not meet the SSI definition of disability/blindness. (SAD - Section 3100) |
REVISED 03/01/10 - CHANGE NO. 03-10
SA DENIAL CODES (CONT'D)
CITIZENSHIP/IDENTITY
N1 |
You did not provide documentation of citizenship and/or identity. (Individual(s) previously received benefits while trying to resolve citizenship code “97”) (Section 3245) |
OTHER REQUIREMENTS
C4 |
You have moved and we are unable to locate you. (Section 3110) |
G6 |
You are not a U.S. citizen or qualified Alien. (Section 3240) |
G7 |
You do not meet the age requirement. (Section 3230) |
H2 |
You did not apply for SSI. (Section 3100) |
REISSUED 10/01/09 - CHANGE NO. 01-10
DISPOSITION CODES - SPECIAL ASSISTANCE WITHDRAWALS
AUTOMATED WITHDRAWAL NOTICES ARE PRODUCED FOR SPECIAL ASSISTANCE.
"This is to notify you that your application for _____ has been withdrawn."
"The reason for this action is:
_______________________________________________
WITHDRAWAL CODES ARE AS FOLLOWS:
W1 |
You asked that your application be withdrawn. (Section 3110) |
W5 |
You asked that your application be withdrawn rather than allow us to match your social security number against other agencies' records. (Section 3400) |
REVISED 10/01/09 - CHANGE NO. 01-10
TERMINATION CODES - ADEQUATE SPECIAL ASSISTANCE TERMINATIONS
Based on the adequate termination code entered on the DSS-8125, EIS will produce a notice to say:
MMDDYY This is the last month you will receive a payment.
All Medicaid benefits will stop.
When Buy-In is present and the Medicaid Class is "C," the following text will be printed:
MMDDYY (Same as termination date) Medicaid will stop paying your Medicare Part B premium.
If an individual(s) becomes ineligible for Medicaid, do not throw away the card. The individual may become eligible again and will need the card.
MMDDYY This is the last month you will receive a payment.
"State rules supporting this action are found in Section _____ of the SA Manual."
50 |
Notice Text - Do not enter. |
51 |
Recipient is deceased. (Section 3100) |
52 |
You have been admitted to an institution and no longer qualify for assistance. (Section 3100) |
53 |
You have requested in writing that your assistance be terminated. (Section 3110) |
REVISED 03/01/10 - CHANGE NO. 03-10
SA ADEQUATE TERMINATION CODES (CONT'D)
54 |
You have been placed in a Medicaid nursing facility or in long-term hospitalization. (Section 3100) |
55 |
We are unable to locate you. Agency mail sent to you has been returned by the post office indicating no known forwarding address. (Section 3110) |
56 |
You are now receiving benefits in another state. (Section 3100) |
57 |
Other (Manual Notice Required) |
6Q |
You have not provided necessary information to document citizenship and/or identity. (Section 3240) |
6R |
You have failed to provide documentation of citizenship and/or identity. (Individual(s) previously received benefits while trying to resolve citizenship code “97’) (Section 3245) |
CAP CASES
When terminating an SAA/SAD case with existing CAP coverage, DO NOT enter a NOTICE OVERRIDE. An automated notice is not produced. Complete a manual notice according to policy requirements.
When completing a DSS-8125 to terminate an SAA/SAD case and you are also entering CAP information, enter "Y" for NOTICE OVERRIDE. Complete a manual notice. If the NOTICE OVERRIDE field is blank, an automated notice will be produced; however, there will be no CAP information on the notice.
REISSUED 03/01/10 - CHANGE NO. 03-10
TERMINATION CODES - TIMELY SPECIAL ASSISTANCE TERMINATIONS
Based on the timely termination code entered on the DSS-8125, EIS will produce a notice to say:
MMDDYY This is the last month you will receive a payment.
All Medicaid benefits will stop.
When Buy-In is present and the Medicaid Class is "C," the following text will be printed:
MMDDYY (Same as termination date) Medicaid will stop paying your Medicare Part B premium.
If an individual(s) becomes ineligible for Medicaid, do not throw away the card. The individual may become eligible again and will need the card.
MMDDYY This is the last month you will receive a payment.
"State rules supporting this action are found in Section ______ of the SA Manual."
REISSUED 03/01/10 - CHANGE NO. 03-10
SA TIMELY TERMINATION CODES (CONT'D)
INCOME
04 |
You and/or your spouse have net income greater than allowed to receive Special Assistance (Section 3210) |
05 |
You and/or your essential person have net income greater than allowed to receive Special Assistance. (SCD) (Section 3210) |
10 |
You did not cooperate in determining the amount of earned or unearned income you might be eligible to receive. (Section 3210) |
RESERVE
15 |
You and/or your spouse have cash, property, bank accounts, life insurance, vehicles, and/or other assets greater than allowed to receive Special Assistance. (SAA and SAD) (Section 3200) |
16 |
You and/or your essential person have cash, property, bank accounts, life insurance, vehicles, and/or other assets greater than allowed for you to receive Special Assistance. (SCD) (Section 3200) |
17 |
You sold, gave away, or assigned real property to someone else. (Section 3200) Manual Notice Required. |
18 |
You sold, gave away, or assigned personal property to someone else. (Section 3200) Manual Notice Required. |
OTHER FACTORS
01 |
You no longer live in North Carolina (Section 3250) |
02 |
Notice Text - Do not enter. |
03 |
You are no longer living in a rest home or group home. Therefore, you are not eligible to receive Special Assistance. (SAA and SAD) (Section 3100) |
REVISED 03/01/10 - CHANGE NO. 03-10
SA TIMELY (OTHER FACTORS TERMINATION CODES (CONT'D)
06 |
You have moved and we are unable to locate you. (Section 3110) |
07 |
You are no longer disabled and therefore no longer qualify for Special Assistance. (Section 3100) |
08 |
You did not provide the information requested to determine your continuing eligibility. (Section 3110) |
09 |
You did not come in for your review appointment and we do not have the information necessary to determine your continuing eligibility. (Section 3320) |
11 |
The completed contribution letters have not been returned. (Section 3210) |
12 |
You refused to allow us to match your social security number with other agencies' records. (SAA and SAD) (Section 3400) |
13 |
I have not received information needed from a collateral source to determine your continuing eligibility. (Section 3320) |
14 |
You did not provide your wage stubs or the completed wage form by the deadline. (Section 3210) |
19 |
You have moved to a county that does not participate in the SCD Program. (SCD) (Appendix C) |
20 |
You have requested that your assistance be terminated. (No written request) (Section 3320) |
21 |
You are eligible for SSI. (SCD) (Appendix C) |
22 |
You are now age 65. Therefore, you are not eligible to receive in the SCD program. You may apply for Medicaid. (SCD) (Appendix C) |
2Q |
You have not provided necessary information to document citizenship and/or identity. (Section 3240) |
2R |
You have failed to provide documentation of citizenship and/or identity. (Individuals previously received benefits while trying to resolve citizenship code “97”) (Section 3245) |
REISSUED 09/01/06 - CHANGE NO. 02-07
AUTOMATIC EIS TERMINATIONS (SYSTEM ASSIGNED - DO NOT ENTER)
67 |
Program and/or category transfers |
68 |
County reassignment |
CAP CASES
When terminating an SAA/SAD case with existing CAP coverage, DO NOT enter a NOTICE OVERRIDE. An automated notice is not produced. Complete a manual notice according to policy requirements.
When completing a DSS-8125 to terminate an SAA/SAD case and you are also entering CAP information, enter "Y" for NOTICE OVERRIDE. Complete a manual notice. If the NOTICE OVERRIDE field is blank, an automated notice will be produced; however, there will be no CAP information on the notice.
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