NC DEPARTMENT OF HEALTH AND HUMAN SERVICES EIS MANUAL

ELIGIBILITY INFORMATION SYSTEM EIS 4300

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NC HEALTH CHOICE – ONGOING CASE MAINTENANCE - PART FIVE

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NC HEALTH CHOICE – ONGOING CASE MAINTENANCE - PART FIVE

I. CHANGE IN INCOME

II. CHANGE OF ADDRESS

III. TRANSFER TO ANOTHER COUNTY

IV. PROGRAM TRANSFER

V. CHANGE IN HOUSEHOLD COMPOSITION

VI. REENROLLMENT IN NC HEALTH CHOICE

VII. OPTIONAL EXTENDED COVERAGE

VIII. CHANGES TO NC HEALTH CHOICE CASES WHICH MAY RESULT IN DELETION/TERMINATION

VIII. (CONT’D)

IX. INDIVIDUALS PLACED IN LONG TERM CARE/ICF-MR

IX. (CONT’D)

X. INDIVIDUAL BECOMES PREGNANT

XI. SOCIAL SECURITY NUMBER CHANGES OR SSN IS ADDED TO THE CASE

XII. INCORRECT EFFECTIVE DATE FOUND AFTER APPROVAL

XIII. CHANGE MEDICAID CLASSIFICATION TO/FROM “J” “K” “S” or “A” (includes changes from j, k, s, or A to mic-n, MIC-1, or maf)

EIS 4300 - NC HEALTH CHOICE – ONGOING CASE MAINTENANCE
PART FIVE

REVISED 01/01/06 - CHANGE NO. 03-06

I. CHANGE IN INCOME

Evaluate changes in income only at re-enrollment.

II. CHANGE OF ADDRESS

Change the address only if the entire assistance unit moves. See MA 3255.

When a child in a multi-person case leaves the household but continues to reside in North Carolina, he remains eligible until the end of the enrollment period. Do not make changes to the case in EIS.

NOTE: A NC Health Choice case MUST have a North Carolina address. If any other State is entered, an error message displays.

III. TRANSFER TO ANOTHER COUNTY

Transfer the case to another county only if the entire case moves to another county. See MA 3255. Follow instructions in EIS 3500 for county transfers for active cases.

Do not make changes to the case if only a portion of the assistance unit moves to another county. The child that moves continues to be eligible for NC Health Choice until the end of the twelve-month enrollment period.

IV. PROGRAM TRANSFER

Recipients of NC Health Choice are evaluated for Medicaid at
re-enrollment. If the individual is eligible for Medicaid, transfer the NC Health Choice case to MIC-N, MIC-1, or MAF. If eligible for any other aid program/category, the individual is terminated or deleted from NC Health Choice and a new application is entered in EIS.

NOTE: An individual receiving MAF, MIC-1, or MIC-N cannot be transferred to NC Health Choice. An application (8124) must be entered into EIS.

V. CHANGE IN HOUSEHOLD COMPOSITION

EIS does not have income edits for add-ons or for regular maintenance for NC Health Choice. Therefore, EIS allows changes to be made to the maintenance amount and needs unit without making changes to the TOTAL COUNTABLE INCOME field or classification when a change in household composition occurs.

See the chart attached to the end of this section with different changes in household composition and how the county worker reacts to the change.

A. Once an individual is authorized for NC Health Choice, he remains in the case the entire 12-month enrollment period unless he becomes ineligible for NC Health Choice. (See VII. below.)

REVISED 01/01/06 - CHANGE NO. 03-06

V. (CONT’D)

B. When a child(ren) is terminated from MIC-N or MIC-1 but is eligible for NC Health Choice and other individuals in the household are eligible for NC Health Choice, approve the NC Health Choice for the eligible individuals with the earliest eligibility date. Add-on the other individuals who are eligible for NC Health Choice with the later effective date.

For example: An individual is receiving MIC-N or MIC-1 but at the time of redetermination is determined ineligible effective 12/31, but is eligible for NC Health Choice effective 1/1. There are two other individuals in the home who are eligible for NC Health Choice effective 12/01. Terminate the MIC-N or MIC-1 individual effective 12/31. Approve the NC Health Choice case effective 12/1 and then add-on to the NC Health Choice case the terminated MIC-N or MIC-1 individual effective 1/1.

C. When a child who is not authorized for NC Health Choice enters a NC Health Choice household during the 12 month enrollment period:

1. An add-on application for NC Health Choice must be entered into EIS. The child is added to the NC Health Choice case for the remainder of the enrollment period of the household if the child is eligible to receive NC Health Choice. Always evaluate the individual for Medicaid eligibility before adding to NC Health Choice.

2. Update the needs unit and maintenance amount (if changed).

3. Do not update the classification or income until redetermining eligibility at the end of the enrollment period (even if the child has income).

D. When a child who is authorized for NC Health Choice moves into a household, which is not authorized for NC Health Choice:

1. The child remains authorized in the original case until the end of the enrollment period.

2. Do not make any changes in EIS.

3. At the end of the enrollment period, the head of the household where the child resides may reapply for the child.

E. When a child who is authorized for NC Health Choice moves into another NC Health Choice household:

1. The child remains enrolled in the original case until the end of the enrollment period of the first household. Do not make any changes to the case in EIS.

REISSUED 02/01/11 - CHANGE NO. 03-11

V.E.(CONT’D)

2. At the end of the enrollment period of household #1, household #2 can apply to have the child added to their NC Health Choice case for the remainder of their enrollment period.

3. An add-on application is required to add the child to household #2’s existing enrollment. Do not redetermine eligibility. Update the needs unit and maintenance amount (if changed). Do not update the classification or income, even if the child has countable income.

4. At the end of household #2’s enrollment period, redetermine eligibility.

VI. REENROLLMENT IN NC HEALTH CHOICE

A. Each case automatically receives a re-enrollment notice during the 11th month of the eligibility period. Postcards will be mailed 10 calendar days prior to the first day of the 11th month. If the 10th calendar day prior to the end of the month falls on a weekend or holiday, the postcard will be mailed on the following workday.

B. If the recipient(s) remains eligible for NC Health Choice, authorize for another 12-month certification period. See
MA 3255, NC Health Choice. A new benefit card is mailed by BCBS according to the following (sample) schedule.

ENROLLMENT END DATE

NEW ENROLLMENT BEGIN DATE

DATE RE-ENROLLMENT KEYED IN EIS

DATE RE-ENROLLMENT PROCESSED BY BCBS

RE-ENROLLMENT GOES INTO BCBS RECYCLE FILE

DATE RE-ENROLLMENT UPDATES IN BCBS SYSTEM

DATE THE NEW NCHC BENEFIT CARD IS MAILED

02/29/2000

03/01/2000

After Pull in January

Next Work Day Following Entry into EIS

Yes

First Work Day of February

Second Work Day of February

02/29/2000

03/01/2000

Sometime Prior to Pull in February

Next Work Day Following Entry into EIS

No

The same day that BCBS processes the Re-enrollment it updates

The Next Work Day Following the Process Date

• All of the above is assuming that there is no error involved in what the dss worker keys and that there are no transmission problems for EIS and no update problems for BCBS. If an error causes the transaction to kick out at BCBS, an EIS Consultant receives an error transmission that must be manually corrected and resent to BCBS. This can cause a delay of one to two workdays.

REVISED 02/01/11 - CHANGE NO. 03-11

VI. (CONT’D)

•

If the benefit package is returned to BCBS for some reason (i.e., incorrect address formatting when keyed into EIS), BCBS returns the package to Recipient Services in the Division of Medical Assistance, who then forwards it to the county dss. This could conceivably cause a 1 to 1 ½ week delay.

• If no re-enrollment is keyed by PULL in February, EIS transmits an automated termination the first workday after PULL to BCBS. BCBS processes the termination the same day the termination is received. If the caseworker comes back later and reopens the case, the reopen is transmitted to BCBS the following work day and processed by BCBS that same day. The NC Health Choice card is mailed the next workday.

C. EIS automatically terminates the case at the end of the
12-month period when:

1. The recipient fails to return the re-enrollment notice;

2. The caseworker fails to update the enrollment period in EIS for another 12 months.

VII. OPTIONAL EXTENDED COVERAGE

A. At re-enrollment, NC Health Choice cases (MIC A/J/K/S) may be transferred to Optional Extended Coverage (MIC/L), if the family income is greater than 200% and less than or equal to 225% of the Federal Poverty Level Income. If eligible, enter adequate change code 53 (EIS 4300 VI), change the class to “L”, and see MA 3255, NC Health Choice. EIS generates an automated notice to the recipient.

B. At the end of the 12-month extended coverage period (MIC/L), EIS automatically terminates the case on PULL night in the 12th month. No notice is generated for these terminations since we do not know if the family continued coverage or not.

If a family that is in the optional extended coverage group reapplies and is found eligible for either MIC-N or NCHC class A/J/K/or S, call the EIS Unit prior to approving the case so that payment of premiums can be verified. See EIS 1200 – State Office Contacts.

VIII. CHANGES TO NC HEALTH CHOICE CASES WHICH MAY RESULT IN DELETION/TERMINATION

NC Health Choice may be terminated or the individual deleted from the case for any one of the following reasons:

A. The recipient acquires comprehensive health insurance.

B. The recipient moves out of North Carolina.

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

VIII. (CONT’D)

C. The recipient is deceased.

D. The recipient voluntarily requests termination of assistance.

E. The recipient turns age 19.

F. The recipient is incarcerated.

G. The recipient becomes eligible for Work First.

H. A child is removed from the home by the department of social services for placement purposes and is eligible for H-SF or I-AS.

1. When a child is removed from the home by DSS and placed in foster care, terminate NC Health Choice if the child is the only individual on the case and approve as H-SF or I-AS. If the NC Health Choice has other individuals on the case, delete the individual from NC Health Choice and approve H-SF or I-AS.

2. If the child returns to the home within the original 12-month enrollment period, terminate H-SF or I-AS. Complete an administrative re-application with the original date of application to authorize NC Health Choice (or add to existing a.u.) for the remainder of the original 12-month enrollment period. The original date of application and original certification from date must be entered into EIS in order for Blue Cross Blue Shield to calculate the correct 12-month enrollment period. Authorize effective the month after Medicaid terminates.

I. A child is approved for SSI Medicaid. EIS automatically terminates/deletes the child and authorizes for M-AD.

J. If the child is subsequently terminated from SSI Medicaid during the same 12-month enrollment period, complete an administrative
re-application to authorize NC Health Choice (or add to existing a.u.) for the remainder of the enrollment period. The original date of application and original certification from date must be entered into EIS in order for Blue Cross Blue Shield to calculate the correct
12-month enrollment period. Authorize effective the month after Medicaid terminates.

K. The recipient becomes eligible for CAP services or Medicaid for payment of long term care.

L. Citizenship/Identity has not been verified.

IX. INDIVIDUALS PLACED IN LONG TERM CARE/ICF-MR

If the recipient is placed in a long term care facility, evaluate eligibility for Medicaid. Delete or terminate the individual from the NC Health Choice case if the individual is Medicaid eligible. If the individual is ineligible for Medicaid, eligibility continues as NC Health Choice for the remainder of the enrollment period.

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

IX. (CONT’D)

Contact the Claims Analysis Section at DMA (Refer to EIS 1200 – STATE OFFICE CONTACTS) if the child is eligible for Medicaid and eligibility needs to be posted for months in which the recipient was authorized for NC Health Choice.

X. INDIVIDUAL BECOMES PREGNANT

A. Complete an eligibility determination to assure that the recipient is eligible for Medicaid. Verify pregnancy and document eligibility in the case record.

B. Send adequate notice to terminate NC Health Choice.

EXCEPTION: IF THE INDIVIDUAL NEEDS PREGNANCY RELATED MEDICAID FOR A RETRO PERIOD ONLY, AND CONTINUES TO BE ELIGIBLE FOR NCHC ONGOING, DO NOT TERMINATE THE NCHC CASE. COMPLETE AN OPEN/SHUT APPLICATION FOR THE MEDICAID COVERAGE AND CONTACT CLAIMS TO DO THE OVERLAY OF ELIGIBILITY.

C. Treat as an administrative application. Enter an unsigned 8124 in EIS. The date of application is the date the recipient requests coverage.

D. Approve ongoing eligibility after the NC Health Choice case terminates. For any months authorized for Medicaid where the individual was already covered under NCHC, the IE will continue to display the NCHC information. Do not attempt to update the IE screen in EIS for months already covered by NC Health Choice. This must be corrected by claims.

E. Contact the Claims Analysis Unit in DMA (EIS 1200 – STATE OFFICE CONTACTS) if “retroactive” coverage of a pregnancy related service is needed. A Claims analyst will take the information necessary to provide coverage.

F. Refer further inquiries about pregnancy related services to Claims Analysis.

XI. SOCIAL SECURITY NUMBER CHANGES OR SSN IS ADDED TO THE CASE

It is important that social security numbers be entered correctly in EIS when a case is dispositioned. The BCBS system uses the SSN as the NCHC Subscriber ID. Once processed, this number becomes permanent in the BCBS system. Changing the SSN in EIS does not change it in the BCBS system. Take the following steps to ensure the correct SSN is entered in EIS for NCHC recipients.

Verify each child’s SSN by using the SOLQ process. Refer to EIS 1107 – STATE ONLINE QUERY/THIRD PARTY QUERY. Document findings in the case record.

A. Check the SSN keyed for ID assignment. Verify that the correct SSN has been keyed and that it belongs to the child. Verify that the numbers have not been transposed.

REVISED 01/01/06 - CHANGE NO. 03-06

XI. (CONT’D)

B. Before keying an approval for NCHC, or releasing an 8125 that may have been placed on hold because of a second party review, verify again that all children have the correct SSNs by reviewing the 8124 online in EIS. This can be done by using the “AD” function to avoid deleting the pending 8125.

D. Once the 8125 to disposition a NCHC application has been processed in EIS, an incorrect SSN cannot be changed at BCBS by a county action. Refer to EIS 4300 Part Three- MAKING CHANGES TO NC HEALTH CHOICE APPLICATIONS and EIS 4300 Part Five - NC HEALTH CHOICE – ONGOING CASE MAINTENANCE.

E. If it is found that a child’s SSN was keyed incorrectly and the child is already receiving NCHC, call an EIS consultant at DMA. Refer to EIS 1200 – STATE OFFICE CONTACTS.

XII. INCORRECT EFFECTIVE DATE FOUND AFTER APPROVAL

Effective dates for NC Health Choice cases that need to be earlier than originally entered in EIS CANNOT be corrected by doing an open/shut application. This only makes it appear that the individual has coverage when in fact, BCBS does NOT have that period covered. Call EIS to get this corrected. Refer to EIS 1200 – STATE OFFICE CONTACTS.

XIII. CHANGE MEDICAID CLASSIFICATION TO/FROM “J” “K” “S” or “A” (includes changes from j, k, s, or A to mic-n, MIC-1, or maf)

A. At Re-enrollment

A change in Medicaid class to another Medicaid class is allowed.

B. During the 12-month Enrollment Period

If a NCHC case is approved or re-enrolled in an incorrect Medicaid class in error, you may change the Medicaid Classification using the following instructions.

1. Do not enter a change code on the 8125. An automated notice will NOT be produced.

2. The effective date will always be the ongoing (EIS Processing) month.

NOTE: IF THE ERROR IS FOUND WITHIN TWO MONTHS OF
RE-ENROLLMENT, THE CHANGE MUST BE MADE AT
RE-ENROLLMENT.

C. For policy information prior to keying this transaction into EIS, refer to MA-3255 – NC HEALTH CHOICE.

CHANGES IN HOUSEHOLD SITUATION – ATTACHMENT

Use this chart to determine appropriate action when a change in situation occurs

which may affect a NC Health Choice household.

TYPE OF CHANGE	REACTION REQUIRED ?	COMMENTS
Address of entire assistance unit changes	Yes	Change address in EIS NOTE: A NC Health Choice case MUST have a North Carolina address. If any other State is entered, an error message displays.
NC Health Choice child leaves the home; other children remain: • The child moves into household not authorized for NC Health Choice • The child moves into another NC Health Choice household	No No No	No change in case until re-enrollment. Child remains in the assistance unit. Evaluate eligibility at re-enrollment. At end of child’s enrollment period, add to remainder of NC Health Choice period in new household if the child is ineligible for Medicaid. Update needs unit and maintenance amount (if necessary). Do not change classification or income.
Child not authorized for NC Health Choice or Medicaid enters NC Health Choice household	Yes	Evaluate for Medicaid. If ineligible for Medicaid add to NC Health Choice case. Update needs unit and maintenance amount. Do not change income or classification.
Child receiving Medicaid has change in situation and Medicaid is terminated.	Yes	If no NC Health Choice case for household, evaluate child for NC Health Choice. If eligible, approve administrative application for NC Health Choice. If others in household already receiving NC Health Choice, and MA child does not have comprehensive insurance, complete add-on (type 6/administrative) application to approve NC Health Choice for the child. Update needs unit and maintenance amount (if necessary). Do not change classification or income.
One child is deleted (no longer eligible) from NC Health Choice case which has more than one child.	Yes	In EIS, adjust needs unit and maintenance amount (if necessary). Do not change classification or income.

TYPE OF CHANGE	REACTION REQUIRED ?	COMMENTS
Budget unit member not authorized for NC Health Choice leaves the home permanently.	No	Evaluate eligibility at re-enrollment.
Family moves to another county	Yes	Complete county transfer in EIS. 2nd county does not have to review until re-enrollment.
Income Increases: • above 150% of FPL • above 200% of FPL	No	No change until re-enrollment.
Income decreases to below MIC limit	No	No change until end of enrollment period
Child moves out of state	Yes	Terminate if only member in case. Delete if other children are in the NC Health Choice case. Update needs unit and maintenance amount (if necessary). Do not change classification or income.
Child acquires comprehensive health insurance (including Medicare)	Yes	Follow instructions for child moves out of state.
Child dies	Yes	Follow instructions for child moves out of state.
Child is incarcerated	Yes	Follow instructions for child moves out of state.
Child becomes eligible for Work First	Yes	Follow instructions for child moves out of state.
Child is removed by DSS and is eligible for HSF/IAS.	Yes	Delete or Terminate. Approve HSF/IAS. If the child is later returned to parental custody during the NC Health Choice enrollment period-complete administrative re-application (with original date of application) to authorize with original enrollment period; effective date of coverage is the month following month of HSF/IAS termination.

TYPE OF CHANGE	REACTION REQUIRED ?	COMMENTS
Child becomes SSI Medicaid eligible	Yes	System will authorize child for Medicaid. If other children remain in the NC Health Choice case, change the # in the needs unit and maintenance amount (if necessary). Do not change classification or income. If child’s SSI stops during original NC Health Choice enrollment period, complete administrative re-application (with original date of application) to authorize with original enrollment period; effective date of coverage is the month following month of SSI MA termination.
Head of Household requests termination	Yes	Terminate case.
Child marries	No	Leave in the NC Health Choice case.
Child turns age 19	Yes	Delete or terminate child. Evaluate for other coverage.
Child enters Long Term Care	Yes	Evaluate for Medicaid. If eligible, delete or terminate NC Health Choice and approve Medicaid. If ineligible for Medicaid, continue NC Health Choice coverage.
NC Health Choice recipient becomes pregnant	Yes	Evaluate for Medicaid. If eligible ongoing, delete or terminate NC Health Choice and approve ongoing Medicaid. If eligible for retro coverage only, complete an open shut application for the Medicaid coverage. Contact Claims Analysis Section at DMA if eligible for Medicaid coverage of pregnancy related services received during months of NC Health Choice eligibility. If ineligible for Medicaid, continue NC Health Choice coverage.
Incorrect Classification Code entered at approval	Yes	Change during the enrollment period unless it is 2 or fewer months prior to reenrollment. The change is effective the ongoing (EIS processing) month. Do not enter a change code on the 8125.

ENROLLMENT END DATE	NEW ENROLLMENT BEGIN DATE	DATE RE-ENROLLMENT KEYED IN EIS	DATE RE-ENROLLMENT PROCESSED BY BCBS	RE-ENROLLMENT GOES INTO BCBS RECYCLE FILE	DATE RE-ENROLLMENT UPDATES IN BCBS SYSTEM	DATE THE NEW NCHC BENEFIT CARD IS MAILED
02/29/2000	03/01/2000	After Pull in January	Next Work Day Following Entry into EIS	Yes	First Work Day of February	Second Work Day of February
02/29/2000	03/01/2000	Sometime Prior to Pull in February	Next Work Day Following Entry into EIS	No	The same day that BCBS processes the Re-enrollment it updates	The Next Work Day Following the Process Date