Family and Children's Medicaid MA-3205 CONDUCTING A FACE-TO-FACE INTAKE INTERVIEW

III. Information regarding the medicaid program

A. Medicaid Coverage Groups

Explain to the individual that the Medicaid program covers groups of people based on certain categorical requirements.

1. Medicaid for the Aged, Blind, and Disabled, including Health Coverage for Workers with Disabilities (HCWD).

Refer to MA-2000, Non-SSI Eligibility Regulations, and MA-2180, Health Coverage for Workers with Disabilities in the Aged, Blind, and Disabled Medicaid Manual.

This program provides full coverage for eligible individuals who are:

a. Age 65 or older, or

b. Blind as defined by the Social Security Administration or a recipient of State Aid for the Blind, or

The Social Security Administration defines blindness as a central visual acuity of 20/200 or less in the better eye, with the use of a correcting lens or a limitation in the field of vision of the better eye that meets specific criteria.

c. Disabled as defined by the Social Security Administration.

(1) The Social Security Administration defines disability as a physical or mental impairment, which prevents an individual from engaging in any substantial gainful activity (or for a child under 18, an impairment of comparable severity), and which has lasted or is expected to last for at least 12 months or result in death. (Substantial gainful activity is not a consideration for HCWD.)

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(III.A.1.c.)

(2) If the individual is not already receiving Social Security benefits based on disability, the Disability Determination Services (DDS) will determine if the individual meets the criteria for disability. Refer to MA-2525, Disability, in the Aged, Blind and Disabled Medicaid Manual. If an HCWD a/r has had his disability terminated within the last 12 months, a new disability determination may not be necessary. See MA-2180, Health Coverage for Workers with Disabilities

2. Medicare Savings Programs (MQB)

Refer to MA-2130, Qualified Medicare Beneficiaries-Q, MA-2140, Qualified Medicare Beneficiaries-B, and MA-2160, Qualifying Individuals-1 in the Aged, Blind, and Disabled Medicaid Manual.

These programs provide limited coverage of services for eligible individuals who are entitled to Medicare.

3. Medicaid for the Working Disabled

Refer to MA-2150, Medicaid-Working Disabled, in the Aged, Blind, and Disabled Medicaid Manual.

This program provides limited coverage of services for qualified disabled working individuals who have lost entitlement to premium free Medicare Part A solely due to earnings as determined by the Social Security Administration.

4. Medicaid for Families and Children

a. Refer to MA-3230, Eligibility of Individuals Under 21MA-3235, Caretaker Relative Eligibility, MA-3240, Pregnant Woman Coverage, MA-3250, Breast and Cervical Cancer Medicaid, in the Family and Children’s Medicaid Manual.

These programs provide full coverage to eligible children under age 21, caretaker relatives of children under age 19, pregnant women, and women enrolled, screened, and diagnosed with breast or cervical cancer including pre-cancerous conditions and early stage cancer.

b. Refer to MA-3265, Family Planning Waiver Medicaid.

This program provides Medicaid for family planning services in order to assist in the reduction of the number of unplanned pregnancies. Women and men over the age of 19 with income up to 185% of the federal poverty level may qualify.

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(III.A.4.)

c. Coverage also includes the Expanded Foster Care Program (EFCP) for IAS and HSF adolescents ages 18, 19, and 20 without regard to the adolescent’s assets or income levels through the month they turn age 21.

5. North Carolina Health Choice for Children

Refer to MA-3255, NC Health Choice, in the Family and Children’s Medicaid Manual. This program provides health insurance for eligible children age 6 through age 18 who are ineligible for Medicaid and have family incomes equal to or less than 200% of the federal poverty level. Children are evaluated for and enrolled in NC Health Choice only after they are determined ineligible for Medicaid.

B. Eligibility Requirements

Explain to the individual that, in addition to meeting the criteria for a Medicaid coverage group, he must also meet the other eligibility requirements including income and, in some cases, resource requirements. Additionally, except for NC Health Choice, the individual must provide and/or cooperate in obtaining proof of citizenship, identity, and state residence. The DMA-5096 is a tool for documenting the applicant’s responses to basic eligibility requirements and for evaluating eligibility under all possible Medicaid coverage groups.

C. Retroactive and Ongoing Medicaid

Refer to MA-3220, Retroactive Coverage

1. Explain to the individual that Medicaid may be used to pay bills incurred in the three months prior to the month of application, if he is otherwise eligible.

a. You must ask, the individual if he has any medical bills in the retroactive months. You must also document his response.

b. If the individual’s income results in a deductible, explain the advantages and disadvantages of applying for Medicaid retroactively as opposed to ongoing. Include a detailed explanation of the reserve and residence requirements during the retroactive period.

2. Explain that ongoing coverage begins the first day of the month of application if all eligibility requirements are met. Discuss the reserve requirements, including burial designation, rebuttal and reduction, and explain that Medicaid cannot be authorized until the reserve requirements are met.

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(III.)

D. Transfer of Resources

Refer to MA-2240, Transfer of Assets, MA-2242, Home Equity Value & Eligibility For Institutional Services, and MA-2245, Undue Hardship Waiver For Transfer of Assets, in the Aged, Blind, And Disabled Medicaid Manual.

Give the individual the DMA-5057/DMA-5057S, Explanation of The Effect of Transfer of Asset (s) On Medical Assistance Eligibility.

E. Deductible

Refer to MA-3315, Medicaid Deductible

1. Based on the client’s statement of income; compute an estimated deductible, if applicable, for both the retroactive and ongoing periods.

2. Explain the deductible to the individual. Include the following information.

a. Medical bills equal to or exceeding the deductible amount must be incurred before Medicaid can be authorized.

b. The individual is responsible for the deductible amount.

c. Explain to the individual whose expenses and what expenses can be used to meet the Medicaid deductible. You UmustU UaskU the individual the following questions and UdocumentU his response in the record:

(1) What regular medical expenses does the budget unit have on a monthly basis? (current expenses)

(2) Does anyone in the budget unit have any unpaid medical expenses for which he is still responsible? (old bills)

(3) Does anyone in the budget unit anticipate any new medical expenses, such as a scheduled hospital stay? (anticipated expenses)

3. If, based on the individual’s statement, it appears that he is or will be within $300.00 of meeting the deductible, explain to the individual that, if all other factors of eligibility have been met, his application may be held for up to six months. See MA-3215, Processing the Application, for procedures.

F. Choice of Programs

1. Explain the program options, including the advantages and disadvantages, for each program for which each individual is potentially eligible. If an individual is potentially eligible in two different programs, explain that he may apply for both.

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(III.F.)

2. Explain that a child age 6 through age 18 cannot be enrolled in NC Health Choice until ineligibility for Medicaid has been established. The individual cannot choose to receive NC Health Choice instead of Medicaid.

3. Some examples of situations when eligibility may exist in more than one aid program/category are:

a. A pregnant woman may be eligible as M-PW, M-AF or, depending on her age, as M-IC.

b. A disabled parent with children under age 19 may be eligible as M-AD or M-AF, including Family Planning Waiver.

c. A disabled individual under age 21 may be eligible as M-AD (including HCWD), M-AF, or M-IC.

For example, Leah is a 19-year-old who was living with her parents. She was in an accident two weeks ago and has a severe head injury. She has been hospitalized since the accident and the full extent of her injuries is still unknown.

Leah may qualify under Medicaid for the Disabled (M-AD), if her injury is severe enough to meet disability requirements, or Family and Children’s Medicaid, as an individual under 21. The IMC must explain the program requirements for each program and the advantages and disadvantages of the programs so the parents can decide which program to apply for or if they should file two separate applications. The issues to be explained include:

(1) Parental Financial Responsibility

(a) Under the M-AF program, the income and resources of the parents must be used to determine her eligibility unless the doctor states she will be out of the home for more than twelve months. Explain the Medicaid deductible and how it can be met. Also explain the resource limit, and that if resources exceed the limit, the individual is ineligible until the resources are reduced.

(b) Under the M-AD program, the income and resources of the parents do not apply to a child age 18 or older.

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(III.F.3.c.)

(2) Disability

To receive under the M-AD category, DDS must determine if Leah’s medical condition is severe enough to meet the disability criteria. Disability is not a requirement to receive under the M-AF program.

Based on the information provided, Leah’s parents may choose to apply for M-AF, M-AD, or may ask that Leah be evaluated for both. Leah may be approved with an M-AF deductible while her disability is being determined under M-AD. If her condition meets the criteria for disability, M-AD can then be approved back to the date of the application, if otherwise eligible.

G. Certification Periods

Refer to MA-3425, Certification and Authorization.

1. Explain to the individual that eligibility is determined for a limited time, which is called the certification period.

2. Explain that the program in which the individual is found eligible determines the length of the certification period.

H. Long Term Care Placement (LTC)/Community Alternatives Programs (CAP)

An application may be taken for an individual under age 21 who plans to enter or is in a nursing facility, an intermediate care facility for the mentally retarded (ICF-MR), a medical institution for medical, surgical or inpatient psychiatric care or a Psychiatric Residential Treatment Facility when the treatment has or is expected to exceed 12 months or who is in need of home and community based services under a CAP waiver program.

When long-term care or CAP assistance is requested, the IMC must explain the following:

1. The concept of long term care budgeting and the patient monthly liability (pml), or the concept of private living budgeting and the CAP monthly deductible. See MA-2270, Long Term Care Budgeting, and MA-2280, Community Alternatives Programs Medicaid Eligibility in the Aged, Blind, and Disabled Medicaid Manual.

2. Parental financial responsibility. See MA-3305, M-AF, M-IC, H-SF Budgeting, and, MA-3325, Long Term Care Budgeting.

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(III.H)

3. The need for a Prior Approval/Continued Care Review form (FL-2/MR-2), if required by policy. Include in the explanation that the Pre-Admission Screen and Annual Resident Review (PASARR) must be completed prior to approval of the FL2/MR2 by the fiscal contractor or approved entity. Also explain that if there is a change in the required level of care, a new FL2/MR2 is required. See MA-3325, Long Term Care Budgeting or MA-2270, Long Term Care Budgeting, in the Aged, Blind, And Disabled Medicaid Manual.

a. Inform the LTC applicant that if an FL-2/MR-2 is required, the individual must be placed within 30 days of the date of the telephone or stamped approval of the recommended level of care.

b. Inform the CAP applicant that an annual assessment (Plan of Care) is required to determine the continued need for CAP services.

4. Explain Estate Recovery rules. See DMA Administrative Letter No. 23-96 and Addenda and DMA Administrative Letter 09-05.

5. Explain transfer of resource regulations. Refer to MA-2240, Transfer of Assets, MA-2242, Home Equity Value & Eligibility For Institutional Services, and MA-2245 Undue Hardship Waiver For Transfer Of Assets, in the Aged, Blind, And Disabled Medicaid Manual.

I. Pre-Need Applications

There is only one type of pre-need application under the Family and Children’s Medicaid program. An application for ongoing assistance may be taken for an individual who is not a resident of North Carolina if the individual expects to meet the state residence requirements within the 45-day application processing period.

1. Explain to the applicant or his representative that the state residence requirements must be met by the 45th day. If the requirement is not met by the 45th day, the application will be denied.

2. Refer to MA-3335, State Residence, and MA-3425, Certification and Authorization, for procedures.

J. Medicaid Identification Card

Refer to MA-3505, Medicaid Identification Card.

Explain to the applicant or his representative the Medicaid identification card and how to use it.

REISSUED 12/01/10 - CHANGE NO. 16-10