Family & Children's Medicaid Change Notices

This is the fifth and final of a series of change notices containing various FC Medicaid manual section corrections, additions, deletions and/or updates that were not included or not updated within the Medicaid policy at publication.

In addition, DMA is converting all figures and attachments into a form or incorporating them into the policy. The links are changed from the figure/attachment to the Forms website.

II. Content of Change

A. MA-3120, SSI Medicaid, is revised to:

1. Remove figures and any reference to figures that have a form number. The links are changed from the figure to the form.

2. Convert Figure 2, into the DMA-5138, Ex Parte Review Checklist (Non-MIC/NCHC Re-Enrollments).

3. Convert Figure 2B, into the DMA-5180, SSI Check Terminated: Information Needed To Determine Medicaid Eligibility.

4. Include Carolina Access name change to Community Care of North Carolina/Carolina ACCESS (CCNC/CA) throughout the policy.

5. Change the name of Food Stamps to Food and Nutrition Services.

B. MA-3207, Receiving Mail-In Applications, is revised to:

1. Remove figures and any reference to figures that have a form number and change the link from the figure to the form.

2. Convert Figure 2, into the DMA-5104, Notice of Incomplete Application.

3. Convert Figure 3, into the Spanish version of the DMA-5104s, Notice of Incomplete Application.

4. Update information on the DMA-5104/DMA-5104s, Notice of Incomplete Application, (formerly referred to as Incomplete Letter), to enable use for the ABD and FC programs.

C MA-3215, Processing the Application, is revised to:

Remove figures and any reference to figures that have a form number and change the link from the figure to the form.

D. MA-3217, Evaluating County/DDS Performance, is revised to:

Incorporate Figure 1, County Level chart into the policy.

E. MA-3225, Application processing-Corrective Action Procedures, is revised to:

1. Convert Attachment 1, into the DMA-5167, County Analysis – Non-Compliance.

2. Convert Attachment 2, into the DMA-5168, Actions Taken On Improper Denials, Withdrawals, or Inquiries Identified In Monitoring.

3. Convert Attachment 3, into the DMA-5169, Report Card Analysis.

F. MA-3250, Breast and Cervical Cancer Medicaid is revised to:

1. Remove figures and any reference to figures that have a form number and change the link from the figure to the form.

2. Convert Figure 7, into the DMA-5135, Date (s) of Emergency Services Requested for An Alien.

G. MA-3255, NC Health Choice, is revised to:

Include Classification of Health Choice Codes J, K and A, that were previously removed.

H. MA-3265, Medicaid Family Planning Waiver, is revised to:

1. Remove figures and any reference to figures that have a form number and change the link from the figure to the form.

2. Include wording, Community Care of North Carolina/Carolina Access (CCNC/CA) throughout policy.

3. Convert Figure 2, the FPW fact sheet into the DMA-5074, Medicaid Family Planning Waiver Fact Sheet.

I. MA-3313, Sponsor Deeming, is revised to:

1. Remove figures and any reference to figures that have a form number and change the link from the figure to the form.

2. Convert Figure 1, into a link to the Affidavit of Support I-864.

J. MA-3315, Medicaid Deductible, is revised to:

1. Remove figures and any reference to figures that have a form number and change the link from the figure to the form.

2. Remove Figure 3. Counties should refer to the DMA website for current public health program information and etc., as needed.

3. Incorporate Figure 4, Applying DRG Policy, into the manual section.

K. MA-3331, Citizenship/Identity SSA Data Match, is revised to:

1. Convert Figure 3, into the DMA-5176, US Citizenship Documentation Birth Certificate Request.

2. Convert Figure 4, into the DMA-5177, Documentation of Identity and Citizenship for US Citizens.

L. MA-3332, US Citizenship Requirements, is revised to:

1. Incorporate Figure 1, the Hierarchy Charts, into the policy.

2. Incorporate Figure 2, Collective Naturalization, into the policy.

3. Convert Figure 3, into the DMA-5176, US Citizenship Documentation Birth Certificate Request.

4. Convert Figure 4, into the DMA-5177, Documentation of Identity and Citizenship for US Citizens.

5 Convert Figure 5, into the DMA-5178, US Citizenship Documentation Desk Reference.

M. MA-3335, State Residence, is revised to:

1. Convert Attachment 2, into the, DMA-5152, North Carolina Residency Declaration.

2. Convert Attachment 3, into the, DMA-5153, North Carolina Residency Applicant Declaration.

N. MA-3340, County Residence, is revised to:

Convert Figure 1, into the DMA-5154, County Transfer Letter.

O. MA-3345, Age/Name/Marital Status, is revised to:

1. Convert Figure 1, into the DMA-5174, Age Verification.

2. Convert Figure 2, into the DMA-5175, Marriage Verification.

P. MA-3365, Child Support, is revised to:

1. Remove figures and any reference to figures that have a form number. Change the link from the figure to the form.

2. Convert Figure 1 into the DMA-5182, Notice of Cooperation in Establishing Paternity and/or Medical Support.

3. Convert Figure 2, into the DSS-5334, Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate in Child Support Enforcement.

4. Convert Figure 3, into the DSS-8104, Second Notice of Right to Claim Good Cause for Refusal to Cooperate in Child Support Enforcement.

Q. MA-3405, Twelve Months Transitional Medicaid, is revised to:

Remove figures and any reference to figures that have a form number. Change the link from the figure to the form.

R. MA-3510, Third Party Recovery, is revised to:

Remove figures and any reference to figures that have a form number. Change the link from the figure to the form.

S. MA-3525, Medicare Buy-In, is revised to:,

1. Remove figures and any reference to figures that have a form number. Change the link from the figure to the form.

2. Eliminate Figure 1, and direct the link to the Social Security Beneficiary Identification Codes.

3. Eliminate Figure 2, and direct the link to the EIS Manual Section, EIS 1107, State Online Query/Third Party Query.

4. Eliminate Figure 3, and direct the link to the DHHS/SSA Listing of Proofs.

5. Eliminate Figure 4, and link to an Application for Search of Census Records.

6. Convert Figure 5, and Figure 6, and direct the link to the Part A and Part B Buy-In Transaction Codes.

7. Remove Figure 7, Listing of State Agency Codes.

8. Remove Figure 9, English and Spanish sample letters of the EIS generated letters to Medicaid recipients age 65 or older or within three months of turning 65 without an RSDI claim number.

T. MA-3530, Corrective Actions and Responsibility for Errors, is revised to:

1. Convert Figure 1, into the DMA-5170, Request for Claims Override.

2. Convert Figure 2, into the DMA-5171, Approval Notice of Retroactive Medicaid Benefits.

3. Convert Figure 3 into the DMA-5172, Erroneous Authorization Dates of Medicaid Eligibility.

U. MA-3535, Recipient Fraud and Abuse Policy and Procedures, is revised to:

1. Remove attachments and any reference to attachments. Convert the attachments to a form or incorporate into or remove from the policy. Change the link from the attachment to the form.

2. Convert Attachment 1, into the DMA-7057, Referral For Investigation.

3. Remove Attachments 2a, 2b and Attachment 3, and place the information on the DMA website under Statistics and Reports, listed as History of Medicare Deductibles, Co-Payments and Premiums, and MAABD & MQB Income History and the MAABD Reserve History.

4. Convert Attachment 4, into the DMA-7058, Investigative Summary. In addition, the format of the form is revised.

5. Convert Attachment 7, into the DMA-7059, Notice of Change in Overpayment for Medical Assistance.

6. Convert Attachment 8, into the DMA-7060, Voluntary Repayment Agreement.

7. Convert Attachment 9, into the DMA-7061, Voluntary Wage Withholding Agreement.

8. Remove Attachments, 10, 11 and 12. These attachments are legal forms that are obtained from local county Clerk of Court or Magistrate offices. Counties are advised to contact their local county Clerk of Court or Magistrate offices to obtain the proper forms.

III. Effective Date and implementation

This policy is effective 11/01/2011. Apply this policy to Medicaid applications taken on or after 11/01/2011 as well as to those presently in process.

IV. Maintenance of Manual

A. Remove: MA-3120, SSI Medicaid, pages 9-12, 15-17 and Figures 1, 2 and 3.

Insert: MA-3120, SSI Medicaid, pages, 9-12, and 15-17.

B. Remove MA-3207, Receiving Mail In Applications, pages 1-4 and Figures 1-3.

Insert: MA-3207, Receiving Mail In Applications, pages 1-4, dated 11/01/11.

C. Remove: MA-3215, Processing The Application, pages 9-10, 15-16 and Figures 1-3.

Insert: MA-3215, Processing The Application, pages 9-10, and 15-16 dated 11/01/11.

D. Remove: MA-3217, Evaluating County/DDS Performance, pages 5-12 and Figure 1.

Insert: MA-3217, Evaluating County/DDS Performance, pages 5-14, dated 11/01/11.

E. Remove: MA-3225, Application Processing-Corrective Action Procedures, pages 1-2, 5-6 and Attachments 1-3.

Insert: MA-3225, Application Processing-Corrective Action Procedures, pages 1-2, 5-6, dated 11/01/11.

F. Remove: MA-3250, Breast and Cervical Cancer Medicaid, pages 7-8, 13-14 and Figure 7.

Insert: MA-3250, Breast and Cervical Cancer Medicaid, pages 7-8, and 13-14 dated 11/01/11.

G. Remove: MA-3255, NC Health Choice, pages 17-22.

Insert: MA-3255, NC Health Choice, pages 17-22, dated 11/01/11.

H. Remove: MA-3265, Medicaid Family Planning Waiver, pages 1-2, 5-8 and 17-24 and Figures 1-3.

Insert: MA-3265, Medicaid Family Planning Waiver, pages 1-2, 5-8 and 17-24 dated 11/01/11.

I. Remove: MA-3313, Sponsor Deeming, pages 1-2 and Figure 1.

Insert: MA-3313, Sponsor Deeming, pages 1-2 dated 11/01/11.

J. Remove: MA-3315, Medicaid Deductible, pages 11-16, 19-24 and Figures 3 and 4.

Insert: MA-3315, Medicaid Deductible, pages 11-16 and 19-26 dated 11/01/11.

K. Remove: MA-3331, Citizenship/Identity SSA Data Match, pages 3-8 and Figures 3 and 4.

Insert: MA-3331, Citizenship/Identity SSA Data Match, pages 3-8, dated 11/01/11.

L. Remove: MA-3332, US Citizenship Requirements, pages 3-8, 11-14 and Figures 1-5.

Insert: MA-3332, US Citizenship Requirements, pages 3-8, and 11-24, dated 11/01/11.

M. Remove: MA-3335, State Residence, pages, 1-4 and 7-8 and Attachments 1-2 and Figure 3.

Insert: MA-3335, State Residence, pages, 1-4 and 7-8, dated 11/01/11.

N. Remove: MA-3340, County Residence, pages 9-12 and Figure 1.

Insert: MA-3340, County Residence, pages 9-12, dated 11/01/11.

O. Remove: MA-3345, Age/Name/Marital Status, pages 3-4, and Figures 1 and 2.

Insert: MA-3345 Age/Name/Marital Status, pages 3-4, dated 11/01/11.

P. Remove: MA-3365, Child Support, pages 5-6, 9-10, 15-16 and Figures 2 and 3.

Insert: MA-3365, Child Support, pages 5-6, 9-10, and 15-16, dated 11/01/11.

Q. Remove: MA-3405, Twelve Months Transitional Medicaid, pages 3-14, and Figures 1-4.

Insert: MA-3405, Twelve Months Transitional Medicaid, pages 3-14 dated 11/01/11.

R. Remove: MA-3510, Third Party Recovery, pages 3 and 4.

Insert: MA-3510, Third Party Recovery, pages 3 and 4 dated 11/01/11.

S. Remove: MA-3525, Medicare Buy-In, pages 5-6, 9-14, 17-21 and Figures 1-5 and 7 and 9.

Insert: MA-3525, Medicare Buy-In, pages 5-6, 9-14, 17-21, dated 11/01/11.

T. Remove: MA-3530, Corrective Actions and Responsibility for Errors, pages 9-12, and Figures 1-3.

Insert: MA-3530, Corrective Actions and Responsibility for Errors, pages 9-12 dated 11/01/11.

U. Remove: MA-3535, Recipient Fraud and Abuse Policy and Procedures, pages 13-14, 19-20, 27-28, 33-34, 39-40, 43-52, 63-64, 79-80, and Attachments 1, 2a, 2b, 3, 4, 7, 8, 9, 10, 11 and 12.

Insert: MA-3535, Recipient Fraud and Abuse Policy and Procedures, pages 13-14, 19-20, 27-28, 33-34, 39-40, 43-52, 63-64, 79-80, dated 11/01/11.

If you have any questions, please contact your Medicaid Program Representative.

Craigan L. Gray, MD, MBA, JD,

Director

CLG:skm

(This material was researched and written by Sandi Morrow, Medicaid Policy Consultant, Medicaid Eligibility Unit).

For questions or clarification on any of the policy contained in these manuals, please contact your local county office.