Family and Children's Medicaid MA-3255 NC HEALTH CHOICE

II. POLICY FUNDAMENTALS AND ELIGIBILITY REQUIREMENTS

The applicant must always meet the following criteria as listed in MA-3230, Eligibility of Individuals Under Age 21;

• Ages 6 through 18.
• A resident of North Carolina as defined in MA-3335, State Residence.
• A US citizen, alien in the US who is exempt from the 5 year bar or qualified alien after five years from date of entry as defined in MA-3332, US Citizenship Requirements or MA-3330 Alien Requirements.
• Not incarcerated.
• Provide his Social Security Number or apply for one.
• Be uninsured as defined in IV. B. below.

A. NC Health Choice Requirements

1. Citizenship/Identity

In order to receive NCHC, a child must be a citizen of the United States or meet alienage requirements. Refer to MA-3332, US Citizenship Requirements or MA-3330 Alien Requirements. Documentation must be obtained, and appropriate C/I code entered on the 8125.

2. Ineligible for Medicaid/Uninsured

The child must be ineligible for full Medicaid benefits under any category and not covered by comprehensive health insurance (See procedures in IV.B., below). Remember, a person can apply even if covered by health insurance. In order to be eligible the insurance must be stopped. However, if an absent parent is court ordered to provide health insurance, this insurance can not be dropped.

a. Evaluate initially for MIC, MAF-N or MAF-C. If any recipients are eligible, authorize in the appropriate aid program/category.

b. Eligibility Under M-AF Medically Needy

When a child is potentially eligible for MAF-M and NC Health Choice, authorize him for MAF-M if medical expenses to meet the deductible have been incurred as of the date of application.

c. Community Alternatives Program (CAP) Evaluation

An individual who requests or receives CAP services may be approved for Medicaid or continue to receive Medicaid, even if a monthly deductible must be met. Do not authorize CAP eligibles for NC Health Choice.

REVISED 04/01/12 – CHANGE NO. 05-12

(II.A.2.)

Failure to Comply with Procedural Requirements

Do not evaluate for NC Health Choice when the a/r would be eligible for Medicaid except for failure to comply with procedural requirements such as providing information. The a/r must be financially ineligible for Medicaid to qualify for NC Health Choice.

Failure of a self-employed individual to provide operational expenses does not constitute failure to comply with procedural requirements. Always request the operational expenses. If operational expenses are not provided by the 45^th day and income causes ineligibility for Medicaid, evaluate for NCHC. Refer to MA-3300, Income.

3. Income Limit

The income limit to be eligible for NC Health Choice is 100% - 200% of the federal poverty level. The countable income must exceed the maximum MIC (or MPW) income level for age/needs unit and not exceed 200% of the poverty level.

NC HEALTH CHOICE FAMILY INCOME LEVELS

# In Needs Unit:	1	2	3	4
>100 - 200% Age 6 and over	931.01 – 1,862	1,261.01 – 2,522	1,591.01 – 3,182	1,921.01 – 3,842
>200 – 225% Optional Extended Coverage	1,862.01 – 2,095	2,522.01 – 2,837	3,182.01 – 3,580	3,842.01 – 4,322

# In Needs Unit:	5	6	7	8
>100 - 200% Age 6 and over	2,251.01 – 4,502	2,581.01 – 5,162	2,911.01 – 5,822	3,241.01 – 6,482
>200 – 225% Optional Extended	4,502.01 – 5,065	5162.01 – 5,807	5,822.01 – 6,550	6,482.01 – 7,292

# In Needs Unit:	9	10	11	12
>100 – 200% Age 6 and over	3,571.01 – 7,142	3,901.01 – 7,802	4231.01 – 8,462	4,561.01 – 9,122
>200 – 225% Optional Extended	7,142.01 – 8,035	7,802.01 – 8,778	8,462.01 – 9,521	9,122.01 – 10,264

Add $660 to Family Income Level (200% of poverty). In addition:

Add $330 to the Minimum Income Level at 100% (Age 6 and over).

Add $743 to Family Income Level (225% of poverty) for Optional Extended Coverage.

REVISED 04/01/12 – CHANGE NO. 05-12

(II.A.3)

The family must pay an enrollment fee if countable income equals or exceeds the following amounts for the number in the needs unit as shown on the chart below.

NCHC Enrollment Fee & Cost Sharing - Over 150% of Poverty

Family Size	Monthly Income	Family Size	Monthly Income
1	1,397.01	7	4,367.01
2	1,892.01	8	4,862.01
3	2,387.01	9	5,357.01
4	2,882.01	10	5,852.01
5	3,377.01	11	6,347.01
6	3,872.01	12	6,842.01
Each Additional $495

4. Resources

There is no resource test in determining eligibility for NC Health Choice.

5. Long Term Care Facilities

Children who require long term care of more than 12 months in a nursing home, ICF-MR, psychiatric hospital/institution, Psychiatric Residential Treatment Facility (PRTF), or other long term care medical facility (including long-term acute care in a hospital) must be evaluated for eligibility for Medicaid.

6. Emergency Services for Non-Qualified Aliens

NC Health Choice does not provide emergency services for non-qualified aliens or qualified aliens during the 5 year bar. Evaluate the applicant for emergency services under Medicaid.

7. Identification Card

NC Health Choice recipients receive an individual identification card from the Division of Medical Assistance (DMA).

a. Each child in the household who is eligible for NC Health Choice will receive his own identification card.

b. Requests for replacement cards are to be completed by the local county Department of Social Services (DSS).

REVISED 10/01/11 – CHANGE NO. 16/11

(II.A.)

8. Transportation Services

NC Health Choice recipients are ineligible for Medicaid funded transportation services.

9. Enrollment Fee / Cost Sharing

a. Enrollment Fee

If countable family income exceeds 150% of the federal poverty level for the appropriate maintenance level, the family must pay a $50.00 enrollment fee for each child to be covered by NC Health Choice, not to exceed $100.00 per family. The enrollment fee is collected by the county and retained to offset administrative costs for NC Health Choice. Enrollment fees do not apply to federally recognized Indian tribes and Alaskan natives.

b. Cost Sharing

(1) A family with income at or below 150%

A family whose combined countable income is at or below 150% of the federal poverty level must participate in cost sharing. Cost sharing can not exceed 5% of the family’s annual income. Copayment amounts are:

(a) $1.00 for each outpatient generic prescription drug and for each outpatient brand-name prescription drug for which there is no generic substitution available.

(b) $3.00 for each outpatient brand-name prescription drug for which there is a generic substitution available

(c) $10.00 for non-emergency visits to the emergency room. If the child is admitted to the hospital or if there is a true emergency then there may not be an emergency room copay.

(2) A family with income above 150%

A family whose combined countable income exceeds 150% of the federal poverty must also participate in cost sharing. Cost sharing can not exceed 5% of the family's annual income. Copayment amounts are:

(a) $5.00 per visit to a provider or outpatient hospital clinic except for well-child visits or for age appropriate immunizations or routine preventive dental checkups.

REVISED 10/01/11 – CHANGE NO. 16-11

(II.A.9.b.(2))

(b) $1.00 for each outpatient generic prescription drug and for each outpatient brand-name prescription drug for which there is no generic substitution available.

(c) $10.00 for each outpatient brand-name prescription drug for which there is a generic substitution available.

(d) $25.00 for non-emergency visits to the emergency room. If the child is admitted to the hospital or if there is a true emergency then there may not be an emergency room copay.

c. Exemption for Federally Recognized Indian Tribes/Alaskan Natives

Members of federally recognized Indian tribes and Alaskan Natives are exempt from enrollment fees and co payments. The two tribes in North Carolina are the Catawba and the Cherokee.

(1) Members of the Cherokee Tribe have identification cards which verify membership.

(2) Members of the Catawba Tribe do not have an identification card.

(3) Accept the applicant’s statement of tribe membership unless questionable. Contact the tribe for verification if necessary.

(4) Do not collect an enrollment fee for these applicants.

(5) The classification code in EIS for tribe members who receive NC Health Choice and whose income exceeds 150% of the poverty level is “S.” The classification for those whose income is at or below 150% of the poverty level is “A.”

(6) The classification code may be changed from “K” to “S” or “J” to “A” during the enrollment period or at re-enrollment. The change will always be effective the ongoing (EIS Processing) month.

Example: The dss determines on May 25^th that a family authorized as “K” classification meets the criteria for “S” or “A” classification. If the classification is entered on or before “pull night” the change in classification will be effective June 1. If the change is entered after “pull night” the change is effective July 1.

Refer to II A. 3 above for income levels.

REVISED 10/01/11 – CHANGE NO.16-11

(II.A.10)

10. Referrals for Fraud/Overpayments

Person(s) who provide incorrect income or fail to report insurance information and are authorized erroneously may be required to repay the monthly premiums and/or any claims that have been paid for each recipient in the case. Periods of ineligibility are established based upon the same guidelines as for overpayment cases in Medicaid. The guidelines and instructions on how to calculate NCHC overpayments can be found in MA-3535, Recipient Fraud and Abuse Policy and Procedures.

The recipient is required to report to the county changes which may affect eligibility such as acquisition of health insurance or moving out of state. Please note that changes in household income do not affect eligibility for NC Health Choice for Children.

Refer NCHC cases in which it appears that an overpayment may have occurred to the agency's program integrity staff for investigation.

B. Income Verification

1. Ask the applicant/recipient to provide pay stubs, copies of checks, business records for self-employment or other written proof of income as requested on the application form DMA-5063 (DMA-5063, Spanish), Medicaid/NC Health Choice Application.

2. Use the same base period as defined in, MA-3300, Income, for MIC applications.

3. Refer to MA-3300, Income, for exceptions to verification of income.

C. Processing Requirements

1. Processing Standard

The application processing standard is 45 days.

2. Enrollment Period

The enrollment period (authorization) is always 12 months for an ongoing case.

REVISED 10/01/11 – CHANGE NO. 16-11

(II.C.2.a.)

a. Enrollment period begins the first day of the month of application if the family is

eligible in that month, or the first day of the month following application in which child(ren) meet NC Health Choice eligibility requirements and have not received Medicaid (the NCHC effective date and the certification from date must be the same).

b. If the child(ren) received Medicaid in the month of application, the NCHC period begins the first day of the following month in which he did not receive Medicaid.

c. If the child(ren) received NCHC in the month of application, the new NCHC period begins the first day of the month following the month of termination.

D. Case Composition

All NC Health Choice eligibles in the household must be reported as one case and have the same case identification number in EIS even if budgeted in separate assistance units. See IV.A. below. This does not apply to individuals eligible for Optional Extended Coverage ("L" classification). Refer to VI.I.3., below.

E. Automated Inquiry and Match Procedures

NC Health Choice is subject to the same inquiry and match requirements as applications and re-enrollments of eligibility for Medicaid for Infants and Children (MIC). Refer to MA-3515, Automated Inquiry and Match Procedures.

F. Child Support Referrals

Referrals to Child Support Enforcement are not required. Do not complete an automated referral in EIS for applications designated as NC Health Choice. The applicant may only be required to cooperate with Child Support Enforcement if there is an existing court order or separation agreement requiring the absent parent to provide health insurance and the absent parent is not complying.(See IV.B.2. below). Otherwise, inform the caretaker that services are available for a fee if he or she is interested in pursuing support and of the location of the IV-D office and phone number if interested.

G. Appeals

Appeal rights for NC Health Choice are the same as for Medicaid. Follow procedures in Section MA-3430, Notice and Hearings Process, for hearings and appeals.

H. Enrollment Into Community Care of North Carolina/Carolina Access

Enroll NCHC children (except MIC-L) into Community Care of North Carolina/Carolina Access (CCNC/CA). CCNC/CA provides the recipient with a medical home and Primary Care Provider (PCP) who manages care for continuity and ensures services are provided that are medically necessary. It is preferred that the recipient be enrolled with a PCP who is participating in a CCNC network which provides more managed care services to the recipient. Auto enroll NCHC recipients who fail to select a PCP within a reasonable time period of 10 calendar days. Refer to MA-3435, Community Care of North Carolina/ Carolina Access for instructions on enrollment procedures.

REISSUED 04/01/11 – CHANGE NO. 01-11