Family and Children's Medicaid Table of Contents

MA-3100 INTRODUCTION

I. PURPOSE

II. MANUAL FORMAT

III. ON-LINE MANUAL

IV. PAPER MANUAL MAINTENANCE

V. PUBLIC ACCESS

MA-3110: DEFINITIONS

I. ACRONYMS

II. PROGRAMS

III. DEFINITIONS

MA-3120 - SSI MEDICAID

I. INTRODUCTION TO SSI

II. OVERVIEW OF AUTOMATED SSI MEDICAID PROCESS

III. COUNTY DSS RESPONSIBILITY WHEN SSI IS APPROVED

IV. COUNTY DSS RESPONSIBILITY FOR ONGOING SSI RECIPIENTS

V. SSI TERMINATIONS

VI. RELATED MEDICAID ISSUES

MA-3200 – Initial contact

I. Introduction

II. Policy principles

III. Types of Contact

IV. discouragement

V. Exceptions to THE right to BE INTERVIEWED the same day the individual appears in the agency

MA-3205 CONDUCTING A FACE-TO-FACE INTAKE INTERVIEW

I. principle

II. Who may apply

III. Information regarding the medicaid program

Iv. Rights and responsibilities

V. TAKING THE APPLICATION

vi. explaining the available services

MA-3207 Receiving mail-in applications

I. Introduction

II. policy principles

III. Procedures

MA-3210 Verification requirements for applications

I. Introduction

II. policy principles

iii. procedures

PROCESSING THE APPLICATION

MA-3215 Processing the Application

i. introduction

ii. Policy Principles

iii. procedures

IV. Reopened Denials, Withdrawals, approvals or inquiries

MA-3217, EVALUATING COUNTY/DDS PERFORMANCE

I. INTRODUCTION

II. policy principles

III. definitions

IV. application processing requirements

v. monitoring tools

VI. Reports

MA-3220 RETROACTIVE COVERAGE

I. INTRODUCTION

II. REQUIREMENTS

III. PROCEDURES

IV. DISPOSITIONS

MA-3225: APPLICATION PROCESSING – CORRECTIVE ACTION PROCEDURES

I. PRINCIPLES

II. REPORT CARD FAILURES

III. WAIVER REQUESTS FOR FAILING THE ADJUSTED APPLICATION REPORT CARD

IV. MONITORING

V. LOCAL CORRECTIVE ACTION PROCEDURES FOR COUNTY DSS NON- COMPLIANCE

VI. TRACKING AND NOTIFICATION OF NON-COMPLIANCE

VII. STATE CORRECTIVE ACTION TEAM

MA-3230 ELIGIBILITY OF INDIVIDUALS UNDER Age 21

I. Policy RULES – INDIVIDUAL UNDER AGE 21, M-AF

II. POLICY RULES – INDIVIDUALS AGE 16 THROUGH 20, HCWD

IIi. POLICY RULES - INDIVIDUAL UNDER AGE 19, M-IC

IV. POLICY RULES - AUTOMATIC NEWBORN, M-AF OR M-IC

V. POLICY RULES - SPECIAL NEEDS ADOPTION Individual under age 18, M-AF

Vi. POLICY RULES - TITLE IV-E INDIVIDUAL UNDER AGE 18, IAS

VIi. POLICY RULES - FOSTER CHILD UNDER AGE 18, H-SF

VIII. COVERAGE OF CHILDREN IN ADOPTION AGENCIES AND CHILD CARING FACILITIES FOR WHOM THE COUNTY DOES NOT HAVE ANY RESPONSIBILITY

ix. POLICY RULES – INDIVIDUAL UNDER AGE 18 WITH PROTECTED MEDICAID STATUS

X. Policy rules - Expanded Foster Care Program (EFCP)

MA-3235 CARETAKER RELATIVE ELIGIBILITY

I. WHO IS A CARETAKER RELATIVE

II. ELIGIBILITY REQUIREMENTS

III. SPECIAL SITUATIONS

MA-3240 PREGNANT WOMAN COVERAGE

I. POLICY RULES APPLICABLE TO PREGNANT WOMAN

II. MPW

III. MAF

IV. RETROACTIVE COVERAGE

V. POST PARTUM COVERAGE

MA-3245 PRESUMPTIVE ELIGIBILITY FOR PREGNANT WOMEN

I. OVERVIEW

II. COUNTY PROCEDURES

MA-3250 Breast and Cervical Cancer Medicaid

I. Background

II. eLIGIBiLITY REQUIREMENTS FOR Breast and Cervical Cancer Medicaid (BCCM)

III. Policy Fundmentals and/or RULES for BCCM

iV. bccCp screening provider procedures for bccm

v. county dss procedures

MA-3255 – NC HEALTH CHOICE

I. INTRODUCTION AND OVERVIEW

II. POLICY FUNDAMENTALS AND ELIGIBILITY REQUIREMENTS

III. APPLICATION PROCEDURES

IV. EVALUATING NC HEALTH CHOICE ELIGIBILITY

V. DISPOSITION OF APPLICATION

VI. ONGOING CASE MAINTENANCE

VII. NC Health choice freeze procedures

VIII. reactivating Children on the Waiting LIST

MA-3260- COMMUNITY ALTERNATIVES PROGRAM (CAP)

I. INTRODUCTION

II. POLICY rULES - APPLICABLE TO ALL PROGRAMS

MA-3265-Medicaid Family Planning Waiver

I. INTRODUCTION AND OVERVIEW

II. POLICY FUNDAMENTALS AND ELIGIBILITY REQUIREMENTS

III. INTAKE PROCEDURES

IV. EVALUATING MEDICAID FAMILY PLANNING WAIVER ELIGIBILITY

V. DISPOSITION OF APPLICATION

VI. ONGOING CASE MAINTENANCE

VII. Medicaid Family Planning Waiver Freeze Procedures

VIII. Reactivating Individuals on the Waiting List

MA-3270 – PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE)

I. BACKGROUND

II. ELIGIBILITY REQUIREMENTS

MA-3300 Income

I. INTRODUCTION

II. REQUIREMENTS

III. APPLICANT/RECIPIENT’S RESPONSIBILITIES

IV. BASE PERIOD FOR MPW APPLICATIONS

V. BASE PERIOD FOR MAF, MIC, NC HEALTH CHOICE, AND HSF APPLICATIONS

VI. BASE PERIOD FOR MAF, MIC, NC HEALTH CHOICE, AND HSF REDETERMINATIONS

VII. BASE PERIOD FOR CERTAIN INCOMES FOR ALL FAMILY MEDICAID PROGRAMS (INCLUDING MPW and NCHC)

VIII. TERMINATED INCOME (Does not apply to MPW or applications for retroactive coverage)

IX. NON-COUNTABLE INCOME

X. COUNTABLE EARNED INCOME

XI. COUNTABLE UNEARNED INCOME

XII. COMPUTATION OF COUNTABLE INCOME FOR MAF-C

XIII. COMPUTATION OF COUNTABLE INCOME FOR MIC, MPW, MAF-N, MAF-M, MAF-D AND NC HEALTH CHOICE

XIV. APPEAL REVERSALS

MA-3305 MAF, MIC, HSF BUDGETING

I. INTRODUCTION

II. POLICY RULES

III. FINANCIAL RESPONSIBILITY

IV. ESTABLISHING ASSISTANCE UNIT, BUDGET UNIT AND NEEDS UNIT

V. DETERMINE ELIGIBILITY

VI. SPECIAL SITUATIONS

VII. family and children's income limit chart

MA-3310 – MPW Budgeting

I. POLICY RULE

II. FINANCIAL RESPONSIBILITY

III. BUDGETING FOR M-PW

IV. DETERMINATION OF INCOME ELIGIBILITY

MA-3313-SPONSOR DEEMING

I. Introduction

II. Definitions

III. policy principles

IV. Aliens exempt from sponsor deeming

V. immigrants affected by alien sponsor deeming

VI. Battered Alien Exemption

VII. Indigent alien Exemption

VIII. Sponsorship Verification and documentation

IX. Income policy

X. resources

XI. time limit for sponsor deeming

MA-3315 MEDICAID DEDUCTIBLE

I. POLICY Principle

II. HOW TO MEET A DEDUCTIBLE

iii. Applying Bills to Deductible

IV. THIRD PARTY RESPONSIBILITY

V. LOANS

MA-3315 FIGURE 4 – DRG Guide

MA-3320-RESOURCES

I. INTRODUCTION

II. REQUIREMENTS

III. WHOSE RESOURCES ARE COUNTED

IV. WHAT RESOURCES ARE COUNTED

V. INCOMPETENCY

MA-3325 LONG TERM CARE BUDGETING

I. INTRODUCTION

II. Requirements For Placement of 12 Months or Less

III. Requirements for Placement of More Than 12 Months

IV. PROCEDURES

V. LONG-TERM CARE OMBUDSMAN

MA-3330 CITIZEN/ALIEN REQUIREMENTS

I. INTRODUCTION

II. PRINCIPLE

III. United States Citizen

IV. QUALIFIED ALIENS

V. Iraqi and Afghanistan Special Immigrants

VI. Immigrants - Refugee Code, Date, Alien ID and Citizenship/Identity Codes

VII. Trafficking Victims

VIII. Battered Alien (Violence Against Women Act)

IX. Public Charge

X. Sponsor deeming

XI. Verifying 40 qualifying Quarters

XII. Non-Qualified Aliens

XIII. COVERAGE FOR EMERGENCY MEDICAL SERVICES

XIV. PROCEDURES TO OBTAIN USCIS VERIFICATION

MA-3331 CITIZENSHIP/IDENTITY DATA MATCH

I. INTRODUCTION

II. Procedures to Verify Citizenship and Identity using SSA Data Match

MA-3335 STATE RESIDENCE

I. principle

II. REQUIREMENTS

III. PROCEDURES

IV. Indicating Intent

V. INDIVIDUAL MOVING TO NC WAS PREVIOUSLY ELIGIBLE IN ANOTHER STATE

VI. INDIVIDUAL PREVIOUSLY ELIGIBLE IN NC MOVES TO ANOTHER STATE

VII. MEDICAL CARE PROVIDED OUTSIDE OF NC

MA-3340: COUNTY RESIDENCE

I. POLICY RULES

II. DETERMINING COUNTY OF RESIDENCE

III. VERIFYING THE COUNTY OF RESIDENCE

IV. APPLICANT MOVes FROM ONE COUNTY TO ANOTHER COUNTY

V. COUNTY REASSIGNMENT OF ONGOING CASES

VI. Transfers keyed to wrong County

MA-3340: FIGURE 1 - Transfer Letter

MA-3345: AGE/NAME/MARITAL STATUS

I. POLICY RULE

II. VERIFICATION PROCEDURES

MA-3350 KINSHIP AND LIVING WITH REQUIREMENTS FOR FAMILIES AND CHILDREN

I. KINSHIP AND LIVING WITH POLICY RULE FOR CARETAKER RELATIVES

II. VERIFICATION OF KINSHIP FOR THE CARETAKER RELATIVE

III. “LIVING WITH” FOR CARETAKER RELATIVE

IV. KINSHIP AND “LIVING WITH” FOR CHILDREN ONLY

MA-3355 ENUMERATION PROCEDURES

I. Policy principles

II. ENUMERATION REQUIREMENTS

III. ENUMERATION PROCEDURES

IV. UPDATING OF SOCIAL SECURITY ID NUMBER

V. SOCIAL SECURITY NUMBER VALIDATION

VI. DOCUMENTATION

MA-3360 LIVING ARRANGEMENT

I. OVERVIEW OF LIVING ARRANGEMENT

II. SPECIFIC TYPES OF INSTITUTIONS/FACILITIES

MA-3365 CHILD SUPPORT

I. INTRODUCTION

II. REQUIREMENTS FOR REFERRING CHILDREN TO THE CHILD SUPPORT ENFORCEMENT AGENCY

III. REQUIREMENTS FOR COOPERATION OF THE CARETAKER

IV. DETERMINING GOOD CAUSE FOR NOT COOPERATING WITH IV-D

V. MAKING A REFERRAL TO IV-D

VI. AUTOMATED REFERRAL PROCESS

VII. PENALTY FOR FAILURE TO COOPERATE

VIII. REPORTING CHANGES TO IV-D

MA-3400 FOUR MONTHS TRANSITIONAL MEDICAID

I. INTRODUCTION

II. Policy Rules

III. PROCEDURES DURING FOUR MONTHS TRANSITIONAL MEDICAID

V. DOCUMENTATION

MA-3405 TWELVE MONTHS TRANSITIONAL MEDICAID

I. INTRODUCTION

II. POLICY RULES

III. GENERAL PROVISIONS

IV. TRANSITIONAL MEDICAID

V. CHANGE IN SITUATION DURING THE TRANSITIONAL MEDICAID PERIOD

VI. OVERVIEW OF EIS TRACKING DURING THE TRANSITIONAL PERIOD

VII. AUTOMATED TRANSITIONAL BENEFIT REPORTING

MA-3410 TERMINATIONS AND DELETIONS

I. INTRODUCTION

II. EXCEPTIONS TO CONTINUING MEDICAID WHEN MEDICAID, INCLUDING WORK FIRST, TERMINATES

III. REQUIREMENTS FOR EX PARTE REVIEW

IV. WHEN WORK FIRST TERMINATES

V. WHEN MEDICAID TERMINATES

VI. SECOND PARTY REVIEW OF WORK FIRST FAMILY ASSISTANCE AND BENEFIT DIVERSION DENIALS AND TERMINATIONS

MA-3415 – CLASSIFICATION AND EVALUATION

i. iNTRODUCTION

II. PROCEDURES

III. REQUIREMENTS

MA-3420 - RE-ENROLLMENT

I. BACKGROUND

II. POLICY PRINCIPLES

III. BEGINNING THE RE-ENROLLMENT PROCESS

IV. TRACKING MAIL-IN RE-ENROLLMENT FORMS

V. EVALUATE RE-ENROLLMENT FORMS UPON RECEIPT

VI. RECEIPT OF CORRECT MAIL-IN FORMs

VII. CONDUCTING THE MAF/MPW FACE-TO-FACE OR THE TELEPHONE INTERVIEW

VIII. DETERMINING ELIGIBILITY

IX. DISPOSITIONS

X. NEWBORN PROTECTION

Xi. CHILD SUPPORT

XIi. COmmunity Care Of North carolina/ Carolina ACCESS (CCNC/CA)

XIII. REOPENS

MA-3425 - CERTIFICATION AND AUTHORIZATION

I. POLICY RULES

II. LENGTH OF CERTIFICATION PERIODS FOR CASES OTHER THAN MPW AND NEWBORN PROTECTION CASES (For MPW and newborn protection cases, see III., below.)

III. LENGTH OF C.P.’S FOR MPW AND NEWBORN CASES

IV. SPECIAL SITUATIONS

V. PRE-NEED APPLICATIONS

VI. REDETERMINATION/REVIEW

VII. AUTHORIZATION

MA-3430 - NOTICE AND HEARINGS PROCESS

I. INTRODUCTION

II. POLICY PRINCIPLES

III. NOTICE PROCEDURES

IV. HEARING PROCESS

COMMUNITY CARE OF NORTH CAROLINA/CAROLINA ACCESS

I. Background

II. Policy Principles

III. DMA RESPONSIBILITY

IV. COUNTY DSS RESPONSIBILITIES

V. CCNC/CA CONTACT PERSON and Back-Up Person

VI. CCNC/CA PROVIDER (PRIMARY DOCTOR/MEDICAL HOME) DIRECTORY

VII. ENROLLMENT

VIII. ASSIGNMENT PROTOCOLS FOR MEDICAID AND NORTH CAROLINA HEALTH CHOICE (NCHC) RECIPIENTS

IX. RECIPIENT EDUCATION

X. INFORMATION AND REFERRAL RESPONSIBILITY

MA-3500 CONFIDENTIALITY

I. INTRODUCTION

II. REQUIREMENTS

III. DEFINITIONS

IV. OWNERSHIP OF RECORDS

V. CLIENT ACCESS AND RELEASE OF INFORMATION

VI. RELEASE OF INFORMATION TO OTHER SOURCES WITHOUT CONSENT

VII. RELEASE OF INFORMATION TO Federal, State and county Law Enforcement

VIII. confidentiality of information received from the social security administration

IX. Confidentiality of eligibility information system (EIS) Data

X. confidentiality of information received from the EMPLOYMENT SECURITY COMMISSION (ESC)

MA-3505 MEDICAID IDENTIFICATION CARD

I. Introduction

II. PROCEDURES

MA-3510 - THIRD PARTY RECOVERY

I. POLICY RULES

II. PROCEDURES

III. TYPES OF THIRD PARTY RESOURCES

IV. INTERVIEW QUESTIONS FOR DETERMINING TYPES OF THIRD PARTY RESOURCES

V. MEDICAID AS PAYER OF LAST RESORT OR AS PRIMARY PAYER

VI. Third Party Recovery Non Compliance

MA-3515: AUTOMATED INQUIRY AND MATCH PROCEDURES

i. introduction

II. POLICY PRINCIPLES

III. MATCHES REQUIRED BY IEVS

IV. OTHER MATCHES

MA-3520 AUTOMATED SOLQ Procedures

I. INTRODUCTION

II. BENEFIT VERIFICATION

III. MANUAL VERIFICATION OF BENEFITS

IV. THE SOLQ/TPQY SYSTEM

V. DOCUMENTATION

MA-3525: MEDICARE ENROLLMENT & BUY-IN

I. INTRODUCTION

II. WHO IS ENTITLED TO MEDICARE?

III. POLICY PRINCIPLES

IV. OVERVIEW OF MEDICARE COVERAGE

V. OVERVIEW OF MEDICARE BUY-IN

VI. EFFECTIVE DATE OF BUY-IN COVERAGE

VII. RECIPIENT ENROLLMENT IN BUY-IN

VIII. COUNTY RESPONSIBILITY TO ASSIST WITH MEDICARE APPLICATION

IX. CHARGEBACKS FOR COUNTY ERRORS

X. PROCEDURES FOR ALIENS

XI. INFORMATIONAL MATERIALS SENT TO COUNTIES

MA-3530 CORRECTIVE ACTION AND RESPONSIBILITY FOR ERRORS

I. INTRODUCTION

II. REQUIREMENTS

III. PROCEDURES

IV. FINANCIAL RESPONSIBILITY

MA-3535 RECIPIENT FRAUD AND ABUsE POLICY AND PROCEDUrES

i. PURPOSE

II. LEGAL RESPONSIBILITY AND REFERENCES

III. NORTH CAROLINA GENERAL STATUTES

III. FRAUD VS. MISREPRESENTATION

IV. Prevention

V. DETECTION

VI. INVESTIGATIONS

VIII. CALCULATING OVERPAYMENTS

IX. North carolina health choice Overpayments

X. CONCLUSIONS AND RECOMMENDATIONS

XI. NOTICES & Appeals

XII. Administrative Collection Procedures

XIII. BankruptcY

XIV. Distribution of Cash Repayment

XV. EPICS Reporting Requirements

XVI. NC Debt Setoff (Tax Intercept) Criteria for Medicaid Claims

XVII. North Carolina educational lottery Interceptions

XViiI. North Carolina Title XIX Medicaid Recipient Profiles

XiX. CITATIONS AND REFERENCES

MA – 3540 TABLE OF CONTENTS

MA – 3540: Medicaid Covered Services

I. Introduction

ii. Policy Principles

iiI. PHYSICIAN SERVICES

Iv. CLINIC SERVICES

V. HOSPITAL INPATIENT SERVICES

Vi. HOSPITAL OUTPATIENT SERVICES

VIi. NURSING FACILITY SERVICES

ViIi. PSYCHIATRIC AND PSYCHOLOGICAL SERVICES

iX. RESIDENTIAL SERVICES

X. MENTAL HEALTH CENTERS

Xi. STATE AND PRIVATE MENTAL HOSPITALS

XIi. NORTH CAROLINA SPECIALTY HOSPITALS

XIii. DENTAL SERVICES

Xiv. CHIROPRACTORS

Xv. PODIATRISTS

XVi. HOSPICE

XVIi. DURABLE MEDICAL EQUIPMENT (DME)

Xiii. HOME HEALTH SERVICES

Xix. PERSONAL CARE SERVICES (PCS)

Xx. HOME INFUSION THERAPY (HIT)

XXi. PRIVATE DUTY NURSING (PDN)

XXIi. PRESCRIPTION DRUGS

XXIii. HEARING AID SERVICES

XXiv. Optical services

xxv. LABORATORY SERVICES

XXVi.RADIOLOGICAL (X-RAY) SERVICES

xxvii.Outpatient specialized therapies

xxViii. health related services provided by independent practitioners

xxix. Health related services provided in public schools

xxx. Anesthesiology Services

XXXi.FAMILY PLANNING SERVICES

XXXII.Ob/Gyn Services

xxxiii.Sterilizations/hysterectomies/abortions

XXXIV.Baby Love and Child service coordination

XXXV.Medicaid for Pregnant women

XXXVI. NURSE-MIDWIFE SERVICES

XXxvII. Nurse practitioners

XXXVIII. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) and health check

XIl. PREVENTIVE MEDICINE SERVICES

XL. Refugee health assessments provided in health Departments

XLI. DIALYSIS SERVICES

XlIi. COMMUNITY ALTERNATIVES PROGRAMS (CAP)

XliII. Case Management for adults and children at risk of abuse, neglect, and exploitation (At-risk case management)

XLIV. CASE MANAGEMENT FOR individuals with HIV

XLV.Medical Transportation

XLVI.BUY-IN PROGRAM

XLVII.MISCELLANEOUS NON-COVERED ITEMS

MA-3550 - MEDICAID TRANSPORTATION

I. BACKGROUND

II. POLICY Principles

III. EXCLUSIONS

IV. eligibility AND ASSESSMENT OF NEED FOR ASSISTANCE

V. Arranging Transportation

VI. methods of transportation and covered costs

viI. sTAFFING

VIII. Safety and Risk Management

IX. Coordination of Transportation Services

X. Reimbursement

XI. Reporting Medically Related Transportation Costs

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