DHHS Home Page NC DHHS On-Line Manuals  
     DHHS Manual Home Manual Admin Letters Change Notices Archive Search Index Help Feedback

SECTION 200: ELIGIBILITY CRITERIA AND APPLICATION PROCESS

Previous Page Table Of Contents Next Page

REVISED: 02/01/2013

Section 200 outlines eligibility criteria and procedures for county departments of social services workers and Social Workers for the Blind to use when accepting applications for Medical/Eye Care Services. Instructions are formatted to illustrate various types of individual circumstances that may be presented at time of application. A copy of the DSB-2001: Application for Eye Care Certification is in Section 400: Reporting Requirements, Part A.

I. PROGRAM ELIGIBILITY

Medical Eye Care Services are available to North Carolina residents based on their need for the service, their income and their Medicaid status. An individual is considered a resident if he/she is in North Carolina voluntarily with the intent to remain and is not an illegal alien. He/she must present a Green card as verification. The Green Card is not green but is an I-551. This is also called a Permanent Resident Card. An I-94 with a temporary I-551 stamp can also be accepted as verification. A Social Security card does not document legal residence. Please note that the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 made significant changes in Medicaid eligibility for individuals who are not citizens of the United States. For detailed definitions in this area, refer to the Medicaid Manual issued by the Division of Medical Assistance.

A. Need for Service

Those individuals having a need for medical eye care services may have symptoms or conditions such as pain or discomfort in their eyes, blurred vision, or obvious ophthalmological disorders, including eye pathology. Other individuals having need for medical eye care services include school-age children who are having difficulty reading from the blackboard or reading textbook print.

The needed service cannot be a service that is reimbursable through any insurance program or any State or Federal program. The Medical Eye Care Program is funded with all State funds and as such must be used as a last resort.

B. Income

Applicants for medical eye care services must meet income criteria based on established net income scales. The income scale represents 100% of the Federal Poverty Level (FPL) and is used to determine eligibility. This scale is based on total cash resources of the family in which the applicant resides including interest/dividends earned from savings accounts, certificates of deposit, and any other resource. The interest/ dividend is counted as income even if the applicant/ recipient does not receive a payment but allows the earned funds to be added to the principal. The family’s total cash resources or net income is defined as the amount remaining after allowable deductions are subtracted from the family’s annual gross income.

C. Medicaid Status

A North Carolina resident who meets financial eligibility criteria would only be eligible for medical eye care services based on Medicaid status if:

II. INSTRUCTIONS FOR COMPLETING DSB-2001: APPLICATION FOR EYE CARE CERTIFICATION

A. Voter Registration

DSB is one of several state agencies in North Carolina required to offer voter registration services (G.S. 163-82.20 effective January 1, 1995). We are required to offer all individuals the opportunity to register to vote or update their voter registration records each time an individual applies for services, for renewal or re-certification of services, or to provide a change of address or name. Please refer to Appendix F in this manual for the agency policy. In the INTERVIEWER USE ONLY SECTION on page 3 of the DSB-2001: Application for Eye Care Certification please check the box that voter registration services have been offered. The link to the Voter Registration policy is http://info.dhhs.state.nc.us/olm/manuals/dsb/VR/man/Voter%20Registration.htm

B. Completing DSB-2001

An individual may apply for medical eye care services in person at their county department of social services (Exception: Forsyth, Mecklenburg, Pitt and New Hanover Counties apply at district DSB office; in Beaufort County apply at The Blind Center, and in Lenoir County at Lions Industries for the Blind) or by mail by completing the following (1) DSB-2001: Application for Eye Care Certification; (2) DHHS-1000: Authorization to Disclose Health Information, and (3) Voter Registration Preference Form. Remind the applicant to complete all applicable sections, to sign the application and other required forms and to mail all items to the county department of social services or the office which mailed forms to him/her.

All completed applications will be reviewed and eligibility determined by the county DSS worker or the Social Worker for the Blind according to program policy. The applications may also be reviewed by the Nursing Eye Care Consultants in the District Office, the Area Social Services Supervisors, and the Chief of the Medical Eye Care program or a designee. If errors are found or if fraud is confirmed, the certification can be canceled at any time. Bills already accrued will be paid but no additional bills will be paid after the revocation.

A copy of the revised DSB-2001 is in section 400.

Specific instructions for completing DSB - 2001: Application for Eye Care Certification:

C. Identifying Information (self-explanatory)

D. Insurance Information

E. Family Members in Household

F. Income Listings

All income of the family unit
must be considered in determining eligibility for medical eye care services. Income is defined as cash or in-kind resources received for labor, services, government or private benefits, or any money available to the a/r and his/her family unit for maintenance. The types of income listed below are examples of income that the applicant must report, where applicable.

G. Verification of Income (Use the “Documentation” column on page 2.)

H. Computation of Gross Income ( Show the amount after the interviewer has changed all income to reflect total monthly income.)

January

05

$158.60

 

January

12

$169.30

 

January

19

$146.20

 

January

26

$152.60

 

February

02

$136.80

 

February

09

$137.10

 

February

16

$159.70

 

February

23

$150.70

 
   

$1,211.00

Total for 8 consecutive weekly pay periods

       

$1, 211.008=

$151.38

$151.38

 
   

x 4.3

weeks/month

   

$650.93

average monthly income

March

05

$268.00

 

March

19

$240.00

 

April

02

$275.00

 

April

16

$246.00

 

April

30

$260.00

 
   

$1,289.00

 
       

$1289.005 =

$257.80

$257.80

 
   

x 2.16

bi-monthly

   

$556.85

average monthly income

January

05

$158.70

 

January

12

$169.30

 

January

19

$000.00

 

January

26

$152.60

 

February

02

$136.80

 

February

09

$137.10

 

February

16

$000.00

 

February

23

$150.70

 
   

$905.20

 
       

$905 8 =

$113.15

$113.15

 
   

x 4.3

weeks

   

$486.55

average monthly income

I. Allowable Monthly Deductions

Allowable deductions apply to all applicants, regardless of adult/child status. Enter amounts of average monthly allowable deductions/expenditures in spaces provided on right-hand side of application.

J. Net Income Scale for All Applicants: Effective Date 03/31/2014

Children and Adults

The worker will use the income scale below to certify financial eligibility for all applicants.

INCOME SCALE

For each additional family member beyond 12, add $4,020 to yearly Maximum Net Income to meet 100% of the poverty guideline.

K. Other Information

L. Determination of Eligibility for Certification Period

The interviewer will determine the eligibility of the applicant when all the financial information and supporting documentation has been received from the a/r, and verified by the interviewer. The certification period will be for six (6) months, beginning on the date financial eligibility is determined by the interviewer.

M. Incomplete Application

The worker will return any application that is incomplete or contains incorrect data to the applicant for completion or correction. See DSB-2032 in Section 400, Part A: Reporting Requirements.

N. Notification of Eligibility Status

Applicants may be notified of their eligibility status while at the office where he/she is making application as soon as the worker completes the required determination, including verification of income and resources or they may be notified by mail (see DSB-2033 in Section 400, Part A). The worker will maintain a copy of the applications eligibility documentation and notification letters for a minimum of 3 years.

When an applicant’s initial eligibility for medical eye care services has been approved, an authorization for services will be printed. Depending on the computer access of the local issuing agent (either the county DSS staff or the local Division of Services for the Blind staff), the consumer will receive the authorization which is for the eye exam only, in one of the ways listed below.

A detailed explanation of the automated authorization and certification process is provided in Appendix B, Medical Eye Care Automation.

III. EYE EXAMINATIONS AND REFRACTIONS

A. General Coverage Restrictions

B. Specific Eye Conditions

1. Cataracts

Yearly evaluations for visual checks and cataract development may be necessary to determine when the recipient is ready for cataract surgery. These visits should not be billed as complete eye examinations. If the Recipient has lost significant vision, then a request should be made of the NECC for a second refraction within the allowed time frame. If acuity is diminished to the point of needing a change of lens power and cataract surgery is not scheduled, then the NECC will determine whether the change meets the guidelines of the Program.

2. Eye Injuries

If a recipient requests an eye refraction at the time of an eye injury or if there is a condition present that could affect acuity (conjunctivitis, blepharitis, etc.), the refraction should be delayed until the problem is resolved and the acuity would not be affected.

3. Diabetic Patients

Diabetic recipients may require more frequent eye refractions or eyeglass lens changes than other recipients. If a new refraction is requested by the physician and the recipient's eye condition has changed, the opthalmologist or the optometrist may request approval from the NECC for an additional refraction and/or new lens if the change meets the Program's guidelines.

4. Glaucoma/Retinal Disease

Recipients with glaucoma/retinal disease may need more frequent eye exams than that allowed by the Program's guidelines. Retinal diseases (diabetic retinopathy, macular degeneration, etc.) are among the leading causes of blindness. Follow-up exams may be authorized by the NECC when recommended by the opthalmologist or optometrist and as long as the recipient remains eligible for the Medical Eye Care Program.

IV. RETROACTIVE AUTHORIZATION FOR EMERGENCIES

Under certain conditions, when emergency cases cannot be prior approved the Division will reimburse charges for services provided prior to authorization. For eye exams, surgery and hospitalization, only emergency cases may be approved retroactively. The following guidelines will apply in all instances:

A. The services provided are consistent with the scope of services covered by the Medical eye Care Program.

B. The service (s) must have been provided no more than ninety (90) days before the date of application.

C. The applicant must have been eligible for services had he/she made application at the time the services were delivered. Verification of income for the period preceding this must be provided by the applicant. The six month certification period would begin the date services were delivered.

D. Approval for emergency eye exams can be given by the Nursing Eye Care Consultants. Prior approval for emergency surgery and treatment will only be given by the State Consulting Ophthalmologist.

E. If emergency surgery is approved by the State Consulting Opthalmologist, and if the recipient needs eyeglasses the Nursing Eye Care Consultant can approve the request if the lens prescription meets the requirements of 0.62 diopters sphere or cylinder.

V. REDETERMINATION OF ELIGIBILITY

The Authorization and the Certificate for Fitting and Dispensing of Eye Glasses are valid for a six (6) month period from date of issuance. If the recipient does not use these forms within this time period, he/she must re-apply for medical eye care services if services are still needed.

Previous Page Top Of Page Next Page



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


     DHHS Manual Home Manual Admin Letters Change Notices Archive Search Index Help Feedback