Family and Children's Medicaid MA-3230 ELIGIBILITY OF INDIVIDUALS UNDER Age 21
V. POLICY RULES - SPECIAL NEEDS ADOPTION Individual under age 18, M-AF
A. Description
Children covered under this section must have special medical or rehabilitative needs, which are barriers to adoption. These special needs are the result of medical, mental or emotional conditions that require periodic treatment or therapy. Other factors considered as special needs are the necessity of placing siblings together to maintain a family group, ethnic background, age, or membership in a minority race. The county foster care or adoption assistance worker makes the determination for special needs of an adoptive child. Section V.B. provides policy for special needs children adopted in North Carolina. Section V.C. provides policy for special needs children adopted in another state now living in North Carolina. Children included under this section are children receiving State Adoption Assistance, TITLE IV-B, and children who were HS-F upon adoption.
REISSUED 11/01/09 - CHANGE NOTICE NO. 12-09
(V.)
B. North Carolina Special Needs Adoption Assistance Children Living In N.C.
These children are ineligible through Title IV-E because at the time of placement in foster care they did not meet IV-E requirements. There may be other extenuating circumstances at the time of placement that preclude IV-E eligibility. The majority of these children are placed in foster care and receive Medicaid under H-SF category; and upon adoption, would not continue to be Medicaid eligible if the adoptive parents’ income and resources were considered. Evaluate these special needs adoptive children under M-AF categorically needy guidelines counting only the child’s income and resources. Do not evaluate these children for MAF-M.
REISSUED 11/01/09 – CHANGE NO. 12-09
(V. B.)
3. Medicaid Application Procedures
a. The Adoption Assistance worker must inform the adoptive family of their right to receive Medicaid for the child when the adoption agreement is finalized.
b. The Adoption Assistance worker will provide form DSS-5095, Child Placement Information and Tracking System, as verification that the child has special medical or rehabilitative needs which would be a barrier to adoption.
c. Field 18 of the DSS-5095, Child Placement Information and Tracking System, will indicate the initial period of the adoption agreement. Field 23 and 26 will indicate the funding source as “State” or “IV-B”. Accept this as verification that the child has special medical needs and is not eligible for IV-E. The child’s adoption records will contain verification of special needs status should it ever be questionable for a child adopted in North Carolina.
d. A signed application, DMA-5063, or DMA-5063 (Spanish) is required. The application may be signed by the adoptive parents, or a representative designated by the adoptive parents.
e. This is an administrative application.
f. Verification Requirements:
(1) Verify the child’s income and resources and compare to M-AF Categorically Needy income and reserve levels.
(2) The budget unit consists of the child only. Do not count the parent’s income and resources.
g. Verify if the potential for third party insurance from any source exists for the child. Report available insurance information on form, DMA-2041, Third Party Health and Accident Resources Information.
4. Children Adopted Prior to 10/1/94 in North Carolina
a. Children with special medical or rehabilitative needs who were adopted without Medicaid coverage, prior to 10/1/94 may qualify for coverage under this group when the child’s records at the time of adoption indicated special medical or rehabilitative needs. Verification of special needs status for these children must come from the Adoption Assistance Worker in the county social services department via form DSS-5095, Child Placement Information and Tracking System.
REISSUED 11/01/09 – CHANGE NO. 12-09
(V.B 4.)
b. An application for Medicaid must be filed by the adoptive parents or a representative designated by the adoptive parents. This is not an administrative application.
c. In order to be eligible as an adopted child with special needs, the child must meet financial eligibility criteria defined in V.B.2 above. In determining eligibility, use current Categorically Needy income and resource levels, not those in effect at the time of adoption.
5. Authorization
a. Key the DSS-8125 screen, authorizing Medicaid under M-AF once the adoption agreement is finalized.
(1) Medicaid classification is “N.”
(2) Certification Period is six months.
(3) If eligible, retroactive coverage may be authorized for up to three months prior to the date of application.
(4) If the child was previously authorized for Medicaid in another category, terminate the coverage and authorize as M-AF the month following the month of termination.
b. Confidentiality
Due to confidentiality requirements associated with adoption procedures, the case worker must follow procedures in MA-3355, Enumeration Procedures, for Children in Foster Care or Adoptive Placement for enumeration.
6. Redetermination
Once the adopted child has been determined eligible on the basis of special needs, he or she remains eligible for Medicaid as long as adoption assistance remains in effect. Do not react to change in child’s assets, resources, or income.
a. Verify the following by contact with the adoptive parents and adoption assistance worker at each six-month review and document in the case file:
REISSUED 11/01/09 – CHANGE NO. 12-09
(V.B. 6. a)
(1) That the adoption agreement has not been terminated.
(2) Changes in third party insurance.
b. A DMA-5063R (redetermination document) is not required.
c. Authorize the child as M-AF with a six-month certification period.
7. Terminations
Adoption assistance will terminate when the child reaches age 18, the state determines that the adoptive parents are no longer legally responsible for the child, the child dies or upon the death of both adoptive parents. Adoption assistance may also be voluntarily terminated by the adoptive parents. At this point, the child is no longer eligible on the basis of special needs.
a. Complete an ex parte review for ongoing Medicaid eligibility under another program prior to terminating assistance unless the parents have specifically requested termination in writing of Medicaid coverage.
b. Once coverage under this group is terminated (e.g. child turns 18), parental financial responsibility applies if the child remains in the home with the parents. Count the adoptive parent’s income and resources when determining eligibility for ongoing Medicaid coverage.
c. Continuous Eligibility does not apply beyond age 18.
8. Children Receiving SSI
Individuals in North Carolina who receive SSI are automatically authorized for Medicaid. If the SSI recipient is a child who is pending adoption, the child’s SSI may be terminated once the child is placed with the adoptive family, as SSI does not disregard parental financial responsibility. Take the following actions:
a. Follow instructions in MA-3120, SSI Medicaid, to complete a Medicaid Ex Parte review.
b. Verify the child’s special needs status and financial eligibility by evaluating the following at the point the adoption agreement is finalized:
(1) Meets the M-AF categorically needy eligibility criteria if the income and resources of the adoptive parents are disregarded.
(2) Lives with the adoptive parent(s), unless temporarily absent.
c. If the child is eligible under special needs criteria, authorize as M-AF. Enter a DSS-8124 screen. Key the DSS-8125 screen to authorize a six-month certification period.
REISSUED 11/01/09 – CHANGE NO. 12-09
(V.)
C. Adoptive Children With Special Needs Living In States Other Than Where They Were Adopted
1. General
Interstate Compact on Adoption and Medical Assistance (ICAMA) is an agreement by which states have the option to provide “special needs” adoption assistance for children entering their state from another ICAMA state. States have the option to participate; therefore, some special needs adoptive children entering or leaving North Carolina may not qualify under this agreement.
County eligibility and adoption workers are encouraged to work together to coordinate services for the special needs adoptive family. ICAMA is administered through the State Division of Social Services.
2. Adoptive Children From Other ICAMA States Living in N.C.
A child with special needs who is a resident of North Carolina and is the subject of an adoption assistance agreement with another ICAMA state shall be accepted as being entitled to receive Medicaid from N.C. provided all eligibility criteria outlined below are met.
These individuals are excluded from citizenship and identity documentation requirements. They are exempt as the social worker must verify citizenship/identity.
a. Special Needs Status
(1) Child must be under 18 years of age
(2) Verify with the adoption worker that the adoption state is an ICAMA state. The State Division of Social Services will keep a current copy of participating states.
If the child is not from an ICAMA state he cannot be evaluated as a “special needs” adoptive child. Evaluate eligibility for all other programs including North Carolina Health Choice (NCHC), counting financial responsibility of the adoptive parents.
(3) The adoptive parent (s) must provide a certified copy of the adoption agreement, Decree of Adoption/Order of Adoption, from the adoption state that verifies special needs adoption assistance.
Request the State Division of Social Services ICAMA Coordinator to forward the ICAMA packet including the ICAMA form 6.01, Notice of Medicaid Case Eligibility/Case Activation and the adoption assistance agreement. The State ICAMA Coordinator can be reached at 919-733-4622.
REISSUED 11/01/09 – CHANGE NO. 12-09
(V.C. 2.)
(4) If the document is not provided, the worker should work with the foster care or adoptive worker in the county to assist the adoptive family in obtaining this information.
b. Financial Eligibility Criteria
The child must:
(1) Meet the M-AF categorically needy eligibility criteria, if the income and resources of the adoptive parent (s) are disregarded, and
(2) Live with the adoptive parent(s), unless temporarily absent.
c. Medicaid Application Procedures
(1) A signed application DMA-5063/DMA-5063 (Spanish), is required. The application may be signed by the adoptive parent(s), or a representative.
(2) This is an administrative application.
(3) Verification Requirements:
(a) Verify the child’s income and resources and compare to M-AF Categorically Needy income and resource levels.
(b) The budget unit consists of the child only. Do not count the parent(s) income or resources.
(c) The child is ineligible as a “special needs” child if his countable income or resources exceed the allowable limits. Evaluate eligibility for all other programs including NCHC, counting financial responsibility of the adoptive parent(s).
(d) Verify if the potential for third party insurance from any source exists for the child. Report available insurance information on form, DMA-2041, Third Party Health & Accident Resources Information.
d. Authorization
Follow the same procedures in place for N.C. Special Needs Adoption Assistance as outlined in B.5., to authorize benefits.
e. Redetermination
Follow the same procedures in place for N.C. Special Needs Adoption Assistance outlined in B.6.
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(V.C.2.)
D. N.C. Special Needs Adoption Assistance Child Moving To Another State
1. Moves to Another ICAMA State
a. Upon notification that a special needs adoption child moved to another state the income maintenance worker should:
(1) Send proper notice that assistance will terminate. Refer to MA-3430, Notice and Hearings Process, to see if timely notice required.
(2) Notify the adoption assistance worker of the change and any available information about the new state of residence.
b. The adoption worker will work with the “ICAMA Coordinator” through the State Division of Social Services office to complete the necessary ICAMA forms needed to notify the ICAMA state. See E.
2. Moves to a non-ICAMA State
a. Upon notification that a special needs adoption child moved to a non- ICAMA state, the income maintenance worker should notify the adoption assistance worker of the change and any available information about the new state of residence.
b. The adoption worker will work with the “ICAMA Coordinator” through the State Division of Social Services office to complete the necessary ICAMA forms.
E. Re-entry into North Carolina
If a child was determined eligible for North Carolina Medicaid on the basis of special needs prior to moving to another state, and later returns to North Carolina, his Medicaid eligibility is reinstated if the adoption agreement remains in effect. Do not react to changes in the child’s resources or income. Treat as a redetermination and follow procedures in V.B.6.
REISSUED 11/01/09– CHANGE NO. 12-09
(V. E.)
REISSUED 11/01/09– CHANGE N0. 12-09
