Chapter XIII: Child Welfare Funding Manual

Appendix



Appendix A – Physician Letter Regarding HIV Status of Child

Date:

Worker:

Address:

Dear:

I am responding to your request for information regarding ____________________________________________

DOB:____________

(To the Physician: Please checks the appropriate boxes below)

Based on accepted diagnostic procedures, the above named foster child has the following classifications:

Levels (Corresponding to classification established by the National Center for Disease Control)

____ E Perinatally exposed infant 0-24 months who cannot be classified as definitely infected, but who has the antibody to HIV, indicating exposure to an infected mother.

____ N Infant, child or youth, who meets one of the CDC definitions for infection, but has no previous signs or symptoms of HIV.

_____ A, B, C A=Mild Signs/Symptoms

B=Moderate Signs/Symptoms

C=Severe Signs/Symptoms

____ T Child aged 0-21 with laboratory evidence of HIV infection who has a resulting terminal diagnosis with a life expectancy of less than six months.

____ Seroreversion Infant, formerly classified as E who has achieved at least age 18 months, has not developed HIV infection and is no longer considered to be at risk of infection from perinatal exposure.

Physician's Signature ______________________ ,M.D.

Address ___________________________

___________________________

An Equal Opportunity / Affirmative Action Emplover

Appendix B – DSS 5758 Request for Reimbursement: Supplemental Board Payment HIV Positive Foster Children

REQUEST FOR REIMBURSEMENT

SUPPLEMENTAL BOARD PAYMENT HIV POSITIVE FOSTER CHILDREN

COUNTY NAME ___________________________________________________ BENEFIT MONTH AND YEAR ________________________

For IV-E Eligible Children:

Client Name Client ID# Client Date of Birth Payment HIV Code Facility ID

Amount Code Number

1.___________________________________________________________________________________________________________________________________

2.___________________________________________________________________________________________________________________________________

3. ___________________________________________________________________________________________________________________________________

4. ___________________________________________________________________________________________________________________________________

5. ___________________________________________________________________________________________________________________________________

6. ___________________________________________________________________________________________________________________________________

For State Funds Eligible Children:

Client Name Client ID# Client Date of Birth Payment HIV Code Facility ID

Amount Code Number

1. ___________________________________________________________________________________________________________________________________

2. ___________________________________________________________________________________________________________________________________

3. ___________________________________________________________________________________________________________________________________

4. ___________________________________________________________________________________________________________________________________

5. ___________________________________________________________________________________________________________________________________

6. ___________________________________________________________________________________________________________________________________

For each child, attach the Statement of Qualifying Diagnosis from the child’s physician verifying each child’s medical status.

Submit form to:

Children’s Services Section, Division of Social Services

325 N. Salisbury Street

Raleigh, NC 27603

Courier # 56-20-25

Telephone # (919)733-9467

Fax # (919) 715-0024

DSS-5758

Appendix C – Request for Adjustment to Foster Care Assistance Payment

REQUEST FOR ADJUSTMENT TO FOSTER CARE ASSISTANCE PAYMENT

Claimant Information

Agency:		CCI?
Name:
Date:
Phone:
E-Mail:

Over = Overage: To return funds received in error FUNDS: IVE, SFH, TEA, IVEW

Retro = Retroactive: To receive payments denied

DESCRIPTION:

REQUEST FOR ADJUSTMENT TO FOSTER CARE ASSISTANCE PAYMENT – EXAMPLE FORM

Claimant Information

Agency:	NC DHHS	CCI?	No
Name:	Tina Bumgarner
Date:	9/20/2004
Phone:	(704) 462-2686
E-Mail:	Tina.Bumgarner@ncmail.net

Over = Overage: To return funds received in error FUNDS: IVE, SFH, TEA, IVEW

Retro = Retroactive: To receive payments denied

DESCRIPTION: Jimmy – Client not eligible for IVE Funding

Sue & Jane - Reviews were not complete, clients not eligible for SFH funding

George - Maximization received in error, client was in level 2 facility and received HRI funding

Request for Adjustment to Foster Care Assistance Payment

Instruction Sheet

Step 1 Complete Claimant information:

• Provide information for contact person who can answer specific questions concerning the adjustment.

Step 2 Determine Adjustment Type To Request

• Overage Request - This request is to return funds received in error.

• Retroactive Request - A request to receive payments not previously paid due to problems with entry or licensure

Step 3 Document Client Information

• Name

• Date of birth

• State identification number (SIS)

• Funding source: IVE, SFH, TEA or IVEW

Step 4 Document claim information

• Service Month

• Gross Claim - The gross claim amount should be the correcting amount.

	Field & Description	Reported	Actual	Gross Amt
Example A	DSS payment of	$ 500	$ 500
	#56 - Clients Resources of	$ -	$ 564
	#50 - Reported payment	$ 500	$ -	$ (500)
	SER for Facility	$ 2,090	$ 2,090
	Maximization to Facility	$ 1,590	$ 1,526
	Field & Description	Reported	Actual	Gross Amt
Example B	DSS payment of	$ 500	$ 500
	Clients Medicaid Resources of	$ -	$ 2,900
	Reported payment	$ 500	$ -
	SER for Facility	$ 2,090	$ 2,090
	Maximization to Facility	$ 1,590	$ -	$ (1,590)

• Net Claim - The net claim is the adjustment after funding percentages apply

		Gross	Percentage	Net
Example A	IVE Client (13 Yrs Old)	$ 490	81.43%	$ 398.99
		$ 10	62.85%	$ 6.29
		$ 500		$ 405.28
	SFH Client (13 Yrs Old)	$ 490	50.00%	$ 245.00
		$ 10	0.00%	$ -
		$ 500		$ 245.00
		Gross	Percentage	Net
Example B	IVE Client (13 Yrs Old)	$ 1,590	62.85%	$ 999.32

Step 5 Provided adequate and descriptive documentation for claim.

• Include payment information (reports or client payment history from state system)

• Include justification for adjustment with a description of the actual versus the reported amounts

Step 6 Submit claim and documentation to the State Division of Social Services.

Appendix D - NC DIVISION OF SOCIAL SERVICES CHILDREN’S FACILITY LICENSE INFORMATION

CHILDREN’S FACILITY LICENSE INFORMATION

ALL INFORMATION IS VERY IMPORTANT- Incomplete applications will delay assignment of the ID #.

Name and Address of Supervising Agency or Owner:

_______________________

Contact Person: ___________________________________Telephone: _________________________________

Complete this part for EACH DFS facility licensed for children.

Name of Facility: MEDICAID PROVIDER NO.

Address of Facility: ________________________

City: ____________________________ Zip: _________________County: ____________________

Facility Phone #: ( ) _____________________ Supervising Agency E-Mail Address: _____________________

Length of Location If less than 5 yrs. previous address ________________________________________

Age range of Clients: _________ Capacity_______ Gender of Clients: _____________

Level of Facility: ______________

Date Current License Effective: _____/_____/_____ Date Current License Expires _____/_____/_____

Corporate Status: (circle one) Non-Profit Profit

This application is for: New Facility: _____

ID # Renewal: _____ (enter ID Number) ___________________

Change of Information: _____ (enter ID Number) ___________________

MAIL (DO NOT FAX) this form along with the current DFS Mental Health License to:

Angelina Spencer, NCDSS-Children’s Services

Black Mountain Center, Building 17

932 Old US 70 Hwy West

Black Mountain, NC 28711

Telephone: 828-669-3388

Note: The approval for and assignment of an ID # is available for residential treatment facilities for children (14V.1300) and Level IV facilities only. You must mail the required information and allow 20 working days for completion. If DFS licensure allows, the effective dates for the ID # will be from the current month of service to the DFS license expiration date. You may send an e-mail to request an ID # application form to Angelina.Spencer@ncmail.net. Once assigned, the facility ID # remains the same, however, you MUST complete this form and send with a copy of your license to the above address anytime there is a change or renewal to your license. Be sure and inform the county DSS of the ID # as soon as you receive it. Verification will be sent to the facility address.

DSS PROCEDURES FOR ID# APPLICATIONS

FOR DFS FACILITES

For new facilities that are licensed by DFS for which you need an ID#, please mail a completed application along with a copy of the DFS license to me at the address below. Please do not fax. New numbers will be assigned at least once a month before the cut-off date for payment. If the DFS license is valid for the month of the current month of service, the ID# will be made effective for the current month of service. For example: A completed application and license is received on March 3^rd, and the DFS license is effective January 1, 2002, then the effective date of the ID# will be February 1, 2002.

If at all possible, please allow at least 20 working days for the review and approval of new ID #s. In addition to reviewing and approving ID #s, we are also setting up files, filing and entering data into the FCFL system, along with other assignments. It is recommended that as soon as you receive the license, you immediately submit the necessary documents to the state DSS.

For facility ID#s that are due to be updated, please submit a completed application along with the renewed DFS license and mail to me at the address below. You will need to complete this pocess anytime there is a change to you license, INCLUDING renewal of licensure. Please do not fax. Be sure and write the ID# on both the application and the DFS license, as these numbers do not change as long as the home remains with your agency.

Angelina Spencer

Children's Services NC Division of Social Services

Black Mountain Center, Building 17

932 Old US 70 Hwy. West

Black Mountain, NC 28711

Attached is a copy of the latest version of the application. Please use this version and please discard any earlier versions you may have. Thanks you.

Note:

No new Therapeutic Homes will be licensed by DFS effective July 18, 2002. For licensure of therapeutic homes after that date or when the current DFS license expires, licensing material must be submitted by the supervisory agency to Angelina Spencer, whose office is also located at Black Mountain Center.

Appendix E – Verification of TEA Eligibility

VERIFICATION OF TEA ELIGIBILITY

Child Name:_______________________________________ Case Number_________

Date of Birth:_________________________

Persons to receive services (including child):

Client Name_________________________________ Client ID#__________________

Client Name_________________________________ Client ID#__________________

Client Name_________________________________ Client ID#___________________

Check all criteria as follows:

_________A child must be experiencing an emergency and the family does not have sufficient resources to meet the need. State the emergency that the child/family is experiencing:

_________The child must have lived with a specified relative within the six months prior to being assessed for the emergency. Identify the specified relative and state the relationship with the child:

_________Identify the service(s) needed (must be on the approved list of services):

_________The services can be provided for up to 364 days only. In the space below, give the end date for services.

Signature of worker____________________________________________________

Date of Authorization___________________________________________________

Last day of Eligibility (364^th day)__________________________________________

*SERVICES

Services provided to the child must be documented within the first 30 days of TEA eligibility determination. The service provided must come under one of these broad headings.

q In-Home Services, including Assessment; Case Management/Service Planning and Coordination, Counseling and Treatment Services; Family Support/Family Preservation; Day Support Services; and, Psycho-Educational Services.

q Out-of-Home Services, including Residential Placement, Care and Treatment in a Family Setting; and, Care and Treatment in a Group Setting.

q Other Services, including Consultation and Education; Other Child Welfare Services; and, Transportation.

Appendix F – MOE Eligibility Documentation Forms

Maintenance-of-Effort

Eligibility Documentation Form for Child Welfare Services

Date Eligibility Determined:

Social Worker Signature:

1. Is the family's income at or below 200% of FPL? Yes No

What is source?

(Family receives Work First, Medicaid/Health Choice, Food Stamps?)

2. Identify the specified relative with whom the child lives and state the relationship.

3. How does provision of service meet TANF purpose?

(TANF purpose related to child welfare: to provide assistance to income-eligible families so that children may be cared for in their own homes or in the homes of a relative)

4. Is child a US citizen or qualified alien? (Please check one)

Yes: No:

For MOE Redeterminations Only

NOTE: MOE Redeterminations of eligibility must be documented annually.

Does the family continue to meet: (1) income eligibility requirements, (2) specified relative requirements, (3) the TANF purpose and (4) citizenship status? Yes: No:

HOW?

(1)

(2)

(3)

(4)

Date Redetermination Completed:

Social Worker Signature:

Appendix G – DSS-5120 Title IV-E Eligibility Determination

DETERMINATION OF

ELIGIBILITY DOCUMENTATION/VERIFICATION FOR FOSTER CARE ASSISTANCE BENEFITS AND/OR MEDICAL ASSISTANCE ONLY

____________________________________ COUNTY DEPARTMENT OF SOCIAL SERVICES

PART I: CHILD INFORMATION

A. 1. 2. 3. 4.

SOCIAL SECURITY NUMBER		SIS I.D.		INDIVIDUAL EIS ID		CO. CASE NUMBER

B.

1. CHILD’S NAME ______________________________ 2. RACE __________________________________ 3. SEX ______________________________________

C.

1. DATE AND PLACE OF BIRTH _____________________________________________ 2. METHOD OF VERIFICATION _____________________________

(copy of birth certificate is preferred, but parent’s statement may be used until birth certificate is obtained)

D.

RESIDENCE AND CITIZENSHIP

	YES	NO	DATE & METHOD OF VERIFICATION (there must be documentation of verification of citizenship status)
U.S. Citizen?
Legal Alien?
Undocumented Alien			Explain

Decision Point:

If child undocumented alien, not IV-E eligible or TEA eligible. Go to Part VI and mark funding source.

1

PART II. INITIAL REMOVAL

AUTHORITY	DATE
1a. Judicial Determination-in reference to best interest/ contrary to welfare (Give date of first court order that contains contrary to welfare/best interest language. Child is not IV-E eligible unless such language is in the very first court order.)		Does the initial court order giving agency custody and placement of child include a judicial finding that remaining in the home is contrary to the welfare of the child, or removal is in the best interest of the child?		YES				NO
1b. Judicial Determination in reference to Reasonable Efforts findings (Give date of court order that contains reference to reasonable efforts. Child not eligible until this languare is obtained.)		Is there an order within 60 days of removal that finds that "reasonable efforts have been made to prevent removal from the home" (court order must specify what efforts the agency made to prevent removal) or that none were possible. (In no case will child be IV-E eligible if this language is not obtained within 60 days of the child’s entry into foster care.)
2. Voluntary Agreement with Parent or Guardian (Give date VPA signed by agency.)		If removed by VPA, were efforts addressed in the document? (All IV-E requirements outlined in law and policy must be met in order for the child to be IV-E eligible. Until all requirements are met, child cannot be IV-E eligible.)
3. Relinquishment as the reason for Placement (Give date of parental consent for all applicable parents.)		(NOTE: This child is only eligible for SFHF or TEA Go to Part, IV).

Decision Point:

If either Part II 1a or 1b is No, child is not IV-E eligible and will never be during this removal period.

Child may be TEA or SFHF. Agencies may elect to proceed with an immediate determination of TEA eligibility. If so, go to Part IV to determine if TEA eligible and continue.

If Part II 1a and 1b are Yes continue to Part III.

PART III: REMOVAL INFORMATION

1. With whom was child living at time of removal?: (check one)

Parent: ________________________________ Non Relative: _______________________________ Relative: ______________________________

(Go to 4a and 4b) (Go to 3 and then follow directions) (Complete 2a and 2b).

2a. If child removed from relative, complete the following:

Name	Address	Relationship

2b. Was this a specified** relative? Y__________N_________

2

** The following Relationships meet the kinship rule:

(1) A parent includes a biological mother or father, a legal father or adoptive parent(s) after the issuance of the final order. (A parent’s blood relationship remains intact even after a child’s adoption into another family. Therefore, the biological or other biological relative may meet the kinship rule even after the child has been adopted into another family.)

(2) An alleged father or other alleged paternal relative.

(3) A blood or half blood relative or adoptive relative limited to: brother, sister, grandparent, great-grandparent, great-great-grandparent, great-great-great grandparent, uncle or aunt, great-uncle or great-aunt, great-great uncle or great-great aunt, nephew, niece, first cousin or first cousin once removed (First cousin once removed is the relationship an individual has to his/her first cousin’s child.)

(4) A step-relative limited to: stepparent, stepbrother, and stepsister.

Decision Point:

If YES to Part III question 2b, proceed to Part IVA and continue. If NO to Part III question 2b, proceed to Part III question 3 and continue.

3. If child removed from a non-relative complete the following for the six months preceding removal. (child must have lived with parent or other specified relative within six months of entering care or child is not IV-E or TEA eligible.)

Child was living with:	Relationship	Date ( From-To):	Date & Method of Verification
Name & Address
Name & Address
Name & Address

If any of the living arrangements in the preceding six months were with a parent, complete Part III 4a, 4b and proceed to Part IV in its entirety. If any of the living arrangements in the preceding 6 months were with a specified relative, proceed to Part IVA (note that the home of the parent or specified relative must be the home home which has been judicially determined to be contrary to the welfare of the child).

Decision Point:

If child removed from a non-specified relative or non-relative and did not live with either a parent or specified relative in the preceding six months, child is NOT IV-E or TEA eligible. Child is eligible for SFHF. Go to Part VI and mark accordingly.

4a. Family Composition (Indicate all persons living in Parent's Home during month of removal).

Name	Relationship	Date of Birth

3

4b. At the time the agency received placement authority, did parental deprivation exist for one of the following reasons:

Yes No

• absence ______ _____

• disability ______ _____

• Unemployment of primary wage earner ______ _____

Decision Point:

If 4b is Yes in any category, continue

If 4b is No in all categories, child is not IV-E eligible. Child may be TEA or SFHF. Proceed to Part V to determine if TEA eligible and continue.

PART IV-FINANCIAL ELIGIBILITY

A. Child’s Income and Reserve

1. Current Income for the Child: 2. Current Reserve for Child

Source of Income	Amount	Date and Method of Verification		Assets	Amount	Bank, Company, Acct. #, etc.	Date and Method of Verification
Child Support Payments				Bank Account
Social Security Benefits Claims #				Stock and Bonds
Dividends from Stocks, Bonds, Other Investments, Trust Funds				Other (specify)
Wages (Less Deductions)				TOTAL RESERVE
Other (Specify)
TOTAL COUNTABLE INCOME:
SSI (not countable, but shown)

3. Were child’s income and reserve less than the amount allowed for one? Y___________N__________ (This must be completed by person qualified to do eligibility

determination).

Decision Point:

If answer to Part III, 2b is yes, thus indicating child was removed from a specified relative other than parent, and Part IV A3 is yes, child would have been eligible for AFDC had an application been made. Therefore, this child is IV-E eligible, go to Part VI and mark accordingly. If answers in Part III indicate the child was removed from a parent, complete remainder of Part IV.

4

PART IV B: PARENT INFORMATION-Complete all information in detail even if B1,B2 and B3 do not reside in removal home.

B1. MOTHER

B2. LEGAL FATHER

B3. PUTATIVE FATHER

Name:

SIS ID Number

Name:

SIS ID Number

Name:

SIS ID Numbers

Current Address:

Current Address:

Current Address:

Telephone Numbers

Date of Birth

Race

Telephone Numbers

Date of Birth

Race

Telephone Numbers

Date of Birth

Race

Social Security Number:

Employed (Yes/No)

Social Security Number:

Employed (Yes/No)

Social Security Number

Employed (Yes/No)

Name of Employer:

Name of Employer

Name of Employer

Address of Employer:

Address of Employer

Address of Employer:

Amount of Monthly Income (From Employment):

Date and Method of Verification-can be parent's word unless reason to doubt

Amount of Monthly Income (From Employment):

Date and Method of Verification-can be parent's word unless reason to doubt

Amount of Monthly Income (From Employment):

Date and Method of Verification-can be parent's word unless reason to doubt

Amount of All Other Monthly Income Including SSA, VA, Unemployment (List sources): Do not count SSI

Amount of All Other Income (List sources): Do not count SSI

Amount of All Other Income (List sources): Do not count SSI

Child care Expense

Number of dependents under 18 and any other additional expense

Number of dependents under 18 and any other additional expense

Paternity Legally Established

Yes No ___

C1.Current Reserve C2. Current Reserve C3. Current Reserve

Assets

Amount

Bank, Company, Acct, #, etc.

Date and Method of Verification

Assets

Amount

Bank, Company, Acct. #, etc.

Date and Method of Verification

Assets

Amount

Bank, Company, Acct. #. etc.

Date and Method of Verification

Bank Account

Bank Account

Bank Account

Stock /Bonds

Stock /Bonds

Stock /Bonds

Other (specify)

Other (specify)

Other (specify)

TOTAL RESERVE

TOTAL RESERVE

TOTAL RESERVE

Send to IMCW to complete budget sheet, page 6, and determine AFDC-connectedness.

5

Part IV E Addendum-Complete if stepparent resides in removal home (income is considered based on the AFDC Need Standard)

1.

STEP PARENT
Name:		SIS ID Number
Current Address:
Telephone Numbers	Date of Birth
Social Security Number:				Employed (Yes/No)
Name of Employer:
Address of Employer:
Amount of Monthly Income (From Employment):			Date and Method of Verification
Amount of Monthly Income (List sources): Do not count SSI

2. 3.

Amount of Alimony and/or Child Support paid to dependents.

Number of step-parent's dependents under age of 18 who live in the house

5A

BUDGETS TO DETERMINE “WOULD HAVE BEEN ELIGIBLE” for AFDC as of July 16, 1996 since all eligibility is based on AFDC requirements as in effect on July 16, 1996 (disregarding the Section 1115(a) waiver that was in effect on that date in NC), all families will qualify as "would have been eligible". Status must be determined. It is not categorical

Complete 1 Budget For Each Natural/Legal Parent In The Removal Home That Does Not Receive SSI Gross Monthly Earned Income (Weekly gross X 4.3, or bi-weekly gross X 2.15) _________ Less Work-Related Expenses __________ Less Actual Childcare Paid Also Convert To Monthly Amount __________ Net Earned Income ___________ Add Unearned Income of Parent and/or His Children, Such as SSA, Child-Support, Unemployment, VA DO NOT COUNT SSI __________ TOTAL NET INCOME ___________ Is Reserve Within Allowable Limit. Yes______________No_________________

Complete For A Stepparent In The Removal Home That Does Not Receive SSI Gross Monthly Earned Income (Weekly gross X 4.3, or bi-weekly gross X 2.15) _________ Less Work-Related Expenses _________ Less Actual Child-Support or Alimony Paid To Dependents Who Live Outside the Home ____________ Net Earned Income ____________ Add Unearned Income of Stepparent and/or His Children, Such as SSA, VA, Unemployment. DO NOT COUNT SSI ____________ Less the Need Standard For the Stepparent And All His Dependents Under age 18 Who Live In The Home. _____________ TOTAL NET INCOME ____________

Add parent'(s) and/or stepparent's TOTAL NET INCOME together. Have this reviewed by IMCW to determine if there is a deficit, then determine if they would have

been eligible for AFDC as of 7/16/96 (disregarding the Section 1115(a) waiver that was in effect on that date in NC) if they had applied. Complete page 7 and proceed to Part VI and mark funding source.

_______________________________________________________________ ________________________________

IMCW DATE

6

DECISION POINT:

If it has been determined that family does not meet AFDC-connectedness because of lack of need or deprivation, child may be SFHF or TEA. If agency elects to determine TEA eligibility at this time, proceed to Part V to determine TEA eligibility

C. CHILD SUPPORT:

Are any of the named parents paying court ordered child support? Yes_________________ No______________________

If Yes, indicate:

Amount______________

Frequency____________

By whom_____________

If No, Do you want to pursue child support? Yes__________________ No___________________________

If No, why not____________________________________________________________________________

D. HEALTH INSURANCE: Do the Parents have health/medical insurance for this child?

Policy Holder Name	Group Name	Insurance Company Name	Insurance Policy/Certificate Number

PART V. TEA ELIGIBILITY DETERMINATION (County decides whether and when to make TEA eligibility determination)

1. Did child reside with a parent or specified relative within the 6 months prior to removal. Yes___________ No ____________

(this should be documented in Part III 3).

DECISION POINT:

If no to Part V question 1, not TEA eligible. Go to Part VI and mark SFHF. If yes to Part V question 1, child may be TEA. Complete 2 and 3.

7

2. Is there documentation in the record that child was in an emergency situation. Yes ________________ No _____________

(If YES, specify)

3. Did family state they did not have the resources to meet the emergency. Yes ________________ No _____________

DECISION POINT:

If yes to 1, 2and 3, child is TEA eligible, go to Part VI and mark accordingly.

Child may be considered for TEA Foster Care Assistance payments if the child is non IV-E and has lived with a parent or specified relative within six months of the TEA eligibility determination. Counties have the option to consider the eligibility of the child for TEA rather than SFHF, but it must be remembered that the TEA Foster Care Assistance payments may be made no longer than 364 days and that the payment system does not reimburse for partial months.

Part VI

If this form is filled out correctly, you have been directed here from a decision point, which will have specified the funding source for this child. Please mark below.

Mark funding source:

IV-E _______________ Medicaid Category _________________________

SFHF _______________

TEA _______________ Certification Period for MA: from__________ to____________.

ALL COUNTY _______________

Placement Information: (For purpose of Medicaid card).

Foster Parent Name and Address: ________________________________________

________________________________________

________________________________________

Attach additional pages as indicated

______________________________________________________________ _________________________________________ _________________

SOCIAL WORKER SUPERVISOR DATE

8

Appendix G – DSS-5120A Title IV-E Eligibility Redetermination

Child’s Name_______________________ DOB_______ Case #____________

Original Placement Authority Type _______________ Date ___________________

Current Funding Source __________________________ __

This form must be completed at least every 12 months or at any time when the agency receives information that would affect any questions listed below. This form is completed for both funding source and Medicaid eligibility. Original Placement Authority refers to how the child entered foster care for the present removal period. Current funding source refers to the category for which payments are being made up to this redetermination date. Children who came into care on a relinquishment are eligible for SFHF (or all county funds) only. This should be reflected in the redetermination.

1. Has the child reached his 18^th birthday? Y___________N__________

Note: If Yes, Child is only eligible for SFHF. See question 8.

2. Answer a or b for children under 18 years of age.

a. If court review was required during this eligibility period, did it occur within the mandated time frames, and does the resulting court order contain the required “reasonable efforts to achieve the permanent plan” language.

Y________ N__________ Date of court review

b. If child’s placement continues based on a Voluntary Placement Agreement, has the court review been held at the mandated time and does the resulting court order either

1) allow VPA to continue? or

2) contain the required “best interest” and “reasonable efforts” language Y_____N_____

3) Give court date

3. Does the child’s situation in reference to private health insurance remain the same as in the last review? Y _________ N __________ How verified?

If “no”, discuss any additional private health insurance available to the child, including the name of the insurance company, the address where the claims

should be mailed, and the name and social security number of the person who carries the insurance. Or discuss the loss of any health insurance.

______________________________________________________________________________________________________________________________________________________________________________________________________ __

4. Has IV-D been given a referral, or additional information, as appropriate? Y____N____

If no, discuss reason ______________________________________________________________

5. Has child been terminated from TEA after 364 days? Y_______N_____NA___________________

6. Does the child's income and reserve remain the same as at previous review? Y_______N_____ How verified?

If "no", describe__ ___________________________________________________________

ANSWER ONLY FOR IV-E CHILDREN REMOVED FROM THE HOME OF THE PARENT(S)

7. Does the deprivation continue because the parents remain absent,

unemployed or disabled or have parental rights been terminated? Y_________N__________

How verified?

_____ _____________________________________________________

8. ANSWER ONLY FOR CHILDREN TURNING 18 OR ALREADY 18, OR EMANCIPATED MINORS WHO REMAIN IN CARE FOLLOWING AN EMANCIPATION

NOTE: If child presently IV-E, child must be changed to SFHF at 18th birthday

a. Has child signed a VPA to remain in foster care? Y______ N_______ Give date signed

b. Is child in school or approved training program? Y_______ N______ How verified

NOTE: If answer is No to either 8a or 8b, child not eligible for SFHF or TEA.

If answers to all questions above are “yes”, the child’s eligibility continues in the category for which foster care reimbursement has been made except for TEA which should have been converted to SFHF after no more than 364 days, i.e. the current funding source as reflected on page 1. (Note the exception above for those turning 18). If answer to any question is “no” you must consult with an IMCW for a possible re-determination of a new payment and/or Medicaid category.

9. Is child currently in a licensed placement (approved facility or foster home)? Y____N____ Give facility or foster home license period

If answer to 9 is “yes”, child is reimbursable in the category for which eligibility has been re-established.

If answer to questions 2 and/or 8 is “no”, child eligible for All County Funds only. May be eligible for Medicaid. Refer to IMCW for Medicaid eligibility determination. If answers to 6 and/or 7, is “no” refer to IMCW to determine correct funding source.

Check if referred to IMCW because there were questions with “no” answers_________

IMCW will use this form to document funding source, reason for change, if any, and sign this form.

_________________________________ ______________________

Social Worker Date

FOR IMCW USE IF REFERRAL MADE:

Describe change and reason:

__________________________________ _____________________

IMCW Date

Funding Source (check one) Medicaid Category_________

IV-E ______ (if applicable)

SFHF ________

ALL COUNTY _______

Appendix H – Adoption Forms

DSS-5115 Adoption Assistance Program Payment Instructions

DSS-5012 Adoption Assistance Eligibility Checklist

DSS-5013 Adoption Assistance Agreement

DSS-5145 Application for Reimbursement of Non-Recurring Adoption Costs

DSS-5146 Agreement for Reimbursement of Non-Recurring Adoption Costs

Special Children Adoption Assistance Fund Forms

DSS-5211 Request for Payment

DSS-5212 Supplemental Adoption Assistance Agreement

DSS-5213 Verification of Child’s Need for Daily Supervision

DSS-5214 Agency Verification of Legal Custody and Child’s Living Arrangement for Past Six Months

DSS-5215 Verification of Child’s Health Condition

ICAMA Forms

DSS-5248 ICAMA Form 6.02 Notice of Action

DSS-5249 ICAMA Form 6.01 Notice of Medicaid Eligibility/Case Activation

DSS-5250 ICAMA Form 6.03 Report of Change in Child(ren)/Family Status

County

AFFIX Department of Social Services Address Label

SIS Number

County Case Number

Child’s Adoptive Name

Adoptive Parent Name

This child is eligible for Adoption Assistance Vendor payment for any combination of psychological, therapeutic, remedial and/or medical services. Adoption Assistance will provide payment, not to exceed $2,400.00 per year, for services related to the treatment of the following condition(s): Describe child’s special needs: _________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ In compliance with NC General Statute 108A-50, the claim must represent only the amount due after all health insurance claims have been processed. Please attach two (2) copies of your bill.

SECTION I - PROVIDER’S INFORMATION

Name

Mailing Address

City State Zip Code

Telephone Number E-mail Address

Signature of Provider Date

SECTION II – DEPARTMENT OF SOCIAL SERVICES INFORMATION

Signature of Director or Agency Representative Position

Telephone Number Fax Number

Use of Form: This form is used to request payment for psychological, therapeutic, remedial and/or medical services by provider. The DSS ???? is to be provided to the adoptive parents to give to each provider of psychological, therapeutic, remedial or medical services.

Instructions to Providers: Complete PROVIDER’S Section and mail to the Department of Social Services for reimbursement.

________________________________________ __________________________________ Date Adoption Became the Plan Date of TPR and/or Relinquishment

If not legally free for adoption, specify steps taken to secure legal clearance and document the determination that the child cannot return to his own home.

1. Date child became the placement responsibility of the Agency: Authority and reason for Placement: 2. Is child eligible for or a recipient of: (Check all that apply) o IV-E Foster Care o SSI o SFHF o Child had been in the placement responsibility of an agency authorized to place children for adoption. o Other source of income (specify): __________________________________________________

3. Specify efforts made to locate a suitable adoptive placement or document why present placement is appropriate.

4. Specify child’s special needs. (Attach documentation to support special needs as it relates to child’s present physical, medical, psychological, psychiatric or therapeutic needs.)

5. If child does not presently have a special need, does child have a potential handicap? If yes, specify reason for potential handicap.

On the basis of information provided above and in supporting documents as required, the following eligibility decision has been made:

a. o Not eligible to receive Adoption Assistance benefits (Specify Reasons):

b. o Eligible

1. Status

o Present o Potential (If potential, state reason)____________________

________________________________________________

2. Benefits (Check all that apply)

o Non-recurring Adoption Expenses (Complete DSS-5145 and DSS-5146)

o Monthly payment—Funding source for cash payment

o IV-E (Child is IV-E foster care or SSI. AFDC eligibility must be determined at time of the removal only.

o IV-B (Child is SFHF foster care and does not receive SSI, or agency gave

custody or guardianship to a person who is now adopting the child.)

o SAF (Child was placed by a private agency.)

o Vendor payments for medical and/or therapeutic services

If the child will receive vendor benefits, attach statement of the condition for which benefits will be paid.

o Medicaid (See MA Manual, Section MA-3454 for non IV-E children)

o Social Services (Post Adoption Services that may be helpful in keeping the family system intact.)

Date Completed	Signature of Agency Representative
Date Adoption Assistance Benefits were discussed with Adoptive Parent(s).
Adoptive Parent(s) state they cannot adopt child without adoption assistance. _______________________ _______________________ Initial of Adoptive Father Initial of Adoptive Mother
Signature of Adoptive Parent(s) ____________________________________________ _________________________________________ Adoptive Father Adoptive Mother

NORTH CAROLINA ADOPTION ASSISTANCE AGREEMENT

______________________________ County Department of Social Services

This Adoption Assistance Agreement has been entered into by and between the _____________________

County Department of Social Services, _____________________________________________________

^Address

_____________________________, North Carolina ________ (______) _________________

^{City Zip Code Telephone Number}

thereafter called the “Agency” and ________________________________________________________

^{Adoptive Parent(s)}

__________________________________________________________________,

^{Mailing Address}

_____________________________, North Carolina _______, (____)____________,

^{City Zip Code Telephone Number}

hereafter called the “Adoptive Parent(s),” for the purpose of facilitating the adoption of ______________

^{Child’s First Name}

born on ______________________, and to aid the adoptive family in providing proper care for this child.

^{Date of Birth}

**************************

I/We, the prospective adoptive parent(s) agree(s) that I/we: o intend to adopt o have adopted

____________________________ and have signed this document o prior to o after finalization of

^{Child’s First Name}

the adoption so that this child can receive Adoption Assistance and other benefits to which s/he is entitled.

PROVISIONS OF THIS ADOPTION ASSISTANCE AGREEMENT

I/We, the Adoptive Parent(s), and the Agency agree to the provisions of those benefits checked below for

which _________________________________________________________ is eligible:

^{Child’s First Name}

This child is eligible for :

o IV-E Benefits

o IV-B Benefits

o State Adoptive Fund Benefits

A.

ASSISTANCE

1. Monthly Cash Payment o No o Yes If “yes” $_______________

^{Monthly Amount}

Begin Date for Monthly Cash Payment: ___________________________________

^{Month Year}

o Month following Decree of Adoption;

o When parent(s) request payment, based on child’s needs; or

o In potential handicap category, when documentation is given to support request for payment.

2. Vendor Payment for any combination of medical and/or therapeutic services

o No o Yes Maximum Amount: $2,400 per year

I/We and the Agency agree that vendor payments in item 2 above are to be provided only for services or treatment related to the following condition(s).

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Vendor payments for the above condition(s) and Medicaid will be available only after the adoptive parent(s) medical insurance has paid or has refused payments of a claim.

**********************************

• If the child is eligible for Title IV-E Adoption Assistance benefits, s/he is also entitled to Medicaid benefits as provided under Title XIX of the Social Security Act and they will be available to her/him in accordance with the procedures of the State in which s/he and the adoptive family live. In addition, if the child is eligible for Title IV-E Adoption Assistance benefits, s/he will be entitled to services in accordance with the provisions of the Title XX program of the State in which s/he and the adoptive family live. An application for Medicaid on behalf of the child needs to be made.

• If the child is eligible for Title IV-B benefits or State Adoptive Fund benefits, s/he is eligible for Medicaid coverage if s/he has special medical or rehabilitative needs and the child’s income and resources are below allowable limits. Financial eligibility is determined by the child’s income only.

For the child receiving a monthly cash payment, I/We and the Agency understand and agree that it is based on the needs of the child. The amount of payment does not exceed the amount of foster care payment for _________________________ if s/he were to remain in a

^{Name of Child}

foster family home. Adjustments in monthly cash payments may be made with the concurrence of the Adoptive Parent(s) and the Agency, based on changes in the needs of the child, circumstances of the adoptive family, or changes in the maximum allowable adoption assistance payment. Documentation of changes in the child’s needs or family’s circumstances may be required.

A. POST-ADOPTION SERVICES

I/We and the Agency agree that post-adoption services will be provided in accordance with the availability of services and resources in the agency and community. I/We understand that post-adoption services is not a continuation of supervision but an agency service given as needed and requested by any of the parties involved in the adoption.

B. ADOPTION ASSISTANCE BENEFITS FOR CHILDREN IN OTHER STATES

1. If the child is eligible for Title IV-E benefits, medical benefits as provided under Title XIX of the Social Security Act (Medicaid) and Social Services as provided under Title XX of the Social Security Act will be available to ________________________ in accordance with

_{Name of child}

the procedures of the State in which the child resides.

2. If the child is eligible for Title IV-B or State Adoptive Fund benefits and the family resides in a state that is a member of the Interstate Compact on Adoption and Medical Assistance (ICAMA), s/he may be eligible for Medicaid coverage in accordance with the provisions of the State in which s/he and the adoptive parents live.

2. The following procedures are necessary to assure the child’s protection in receipt of medical care (Title XIX) and social services (Title XX) for North Carolina children living in a state in other than North Carolina. These procedures are applicable regardless of whether the child moves prior to or following finalization of the legal adoption process.

(a) The Adoptive Parent(s) must provide the Agency with their complete out-off state mailing address including names of the Adoptive Parent(s) and child.

(b) The Agency will provide the appropriate authorities in the resident state with the Adoptive Parent(s)’ address and documentation of the child’s eligibility for Adoption Assistance. This includes the completion of the necessary forms for the Interstate Compact on Adoption and Medical Assistance (ICAMA). The Agency will request that the resident state notify the Adoptive Parent(s) of the agency to contact and the steps needed to apply for Medicaid and Title XX services as provided by the State.

(c) The Adoptive Parent(s) will be responsible for following through with the required application process to assure that medical care and social services will be provided to the child in accordance with the procedures and provisions of the resident state.

A. NOTIFICATION OF CHANGE

1. The Adoptive Parent(s) will immediately notify the Agency, in writing, of any address change so that receipt of benefits will not be delayed.

2. The Adoptive Parent(s) will immediately notify the Agency, in writing, if they are no longer legally responsible for the care and custody of the child or are no longer providing financial support for the child. This includes, but is not limited to, removal from the home and placement into out of home care due to a substantiated report of child abuse or neglect, child’s marriage, death, or entry the military service.

3. The Agency will immediately notify the Adoptive Parent(s), in writing, of changes in Adoption Assistance payments resulting from increases or decreases in allowable benefits. Other adjustments will be made upon a request from the Adoptive Parent(s) at the time of the request.

A. TERMINATION OF ADOPTION ASSISTANCE BENEFITS TO THE CHILD

Adoption Assistance benefits to the child will be terminated in any of the following circumstances upon written notice to the adoptive parents(s):

1. Upon the Adoptive Parent(s)’ request;

2. Upon the child’s reaching the age of eighteen years;

3. Upon the child’s death;

4. Upon the death of the adoptive parent(s) of the child (one, in a single parent family and both , in a two-parent family);

5. Upon termination of legal responsibility for the child by the Adoptive Parent(s); and

6. Upon determination by the state that the Adoptive Parent(s) are no longer providing any support for the child. “Any support” is defined as various forms of financial support such as paying for family therapy, tuition, clothing, maintenance of special equipment in the home, or paying someone else to provide for the child.

A. NOTICE OF RIGHT TO APPEAL

I/We, the Adoptive Parent(s) may appeal the Agency’s decision to reduce, change, or terminate Adoption Assistance benefits in accordance with rules and procedures of North Carolina’s fair hearing and appeal process.

Information as to procedures to follow in filing an appeal may be requested from this Agency or any North Carolina county department of social services.

B. DURATION

This Agreement shall remain in effect regardless of the State of residence of the child and Adoptive Parents(s) at any given time. This Agreement will expire permanently on the child’s eighteenth birthday unless termination occurs earlier as a result of one or more of the conditions set forth in Section E, Termination of the Adoption Assistance Agreement.

C. ACKNOWLEDGEMENT

In completing and signing this Agreement, I/We certify that the information provided herein is true, accurate and complete to the best of my knowledge. In addition, I/We are aware that if I make a willfully false statement or representation, or use other fraudulent methods to obtain adoption assistance benefits to which I/We are not entitled, or greater than that, to which I/We are entitled, I/We can be found guilty of a felony or misdemeanor under appropriate state or federal law.

XI. SIGNATURES

I/We, the Adoptive Parent(s), and the Agency, have read, understand, and agree to the terms and provisions of this Agreement

_____________________________________ ________________________________

^{Signature of Adoptive Mother Date Signature of Adoptive Father Date}

_____________________________ _________________________

^{Print Full Name of Adoptive Mother Print Full Name of Adoptive Father}

^{_____________________________________________ ________________________________________}

^{Social Security Number of Adoptive Mother Social Security Number of Adoptive Father}

^{_____________________________________________ ________________________________________}

^{Signature of Casemanager Date Print Full Name of Casemanager}

^{_____________________________________________ ________________________________________}

^{Signature of Agency Director or Designee Date Print Full Name Agency Director or Designee}

*********************

A signed copy of the Adoption Assistance Agreement was given/mailed to the adoptive Parent(s) on:

__________________________________

Date

STATE OF NORTH CAROLINA

APPLICATION FOR REIMBURSEMENT OF

NON-RECURRING ADOPTION COSTS

CONFIDENTIALITY STATEMENT: The personal information requested on this form will be used to determine entitlement to non-recurring adoption costs under the Title IV-E Adoption Assistance Program administered by the North Carolina Department of Health and Human Services. All personal information on this form will be treated as confidential pursuant to N.C.G.S. 48-9-102.
COUNTY OFFICE USE ONLY
Case Number	Date of Application			Received By
SECTION 1 – APPLICATION INFORMATION
Name of Adoptive Mother (first, middle, last)					Social Security Number
Name of Adoptive Father (first, middle, last)					Social Security Number
Address (house number, street, city, ZIP code)					County
Name of child for whom application is being made (first, middle, last)		Date of Birth	Sex ¨ Male ¨ Female		Social Security Number
SECTION II – ELIGIBILITY DETERMINATION
We (I), the undersigned, apply for reimbursement of non-recurring costs for affecting the adoptive placement of the above named child who has been determined as “a child with special needs”. We (I) understand that reimbursement is limited to a maximum of $2,000.00. We (I) understand that approval of our (my) request is based on meeting the following three (3) eligibility requirements:
A. The child must meet all three (3) of the requirements listed below to be determined as “special needs”. 1. The child is considered to be a child with special needs and in need of adoption assistance due to one or more of the following conditions: (Check which apply.) ¨ Child is member of a sibling group needing placement together; ¨ Age of child; ¨ Ethnicity or member in certain minority groups; or Child has one or more of the following handicaps as determined and documented by a licensed physician: ¨ Medical Condition; ¨ Physical Handicap; ¨ Mental Handicap; or ¨ Emotional Handicap ¨ High-risk for medical, physical, mental or emotional handicap due to heredity, congenital or other documented factor 2. Complete either (a) or (b) below depending upon whether reasonable efforts were or were not made. (a). Reasonable but unsuccessful efforts have been made to place the child without providing adoption assistance. (Check which apply.) ¨ Reviewed available approved adoptive families; ¨ Child registered on NCKIDS or other appropriate adoption exchanges; ¨ Featured child using various recruitment techniques (TV, newspaper, poster, adoption picnic, adoption parties etc.); ¨ Lack of available approved, appropriate, interested families able to meet the child’s need without adoption assistance; ¨ Utilized the services of State Contract Agencies; or ¨ Other (please specify.) _______________________________________________________________________________ (b) Reasonable efforts were not made to place the child without the use of adoption assistance because to do so would be against the best interest of the child. (Check which apply.) ¨ Child has developed a significant emotional attachment to the foster parent(s); ¨ Foster parent(s) has expressed a willingness to adopt the child, and the child meets eligibility requirements; ¨ An appropriate relative became available ¨ Other (please specify.) _______________________________________________________________________________ 2. The child adopted or to be adopted cannot or should not be returned to the home of the biological parent(s). Check one for each biological parent. (Attach copy of documents) (a). Biological Mother ¨ Court Ordered Termination of Parental Rights; ¨ Death of Parent; ¨ Relinquishment by Biological Mother; or ¨ Decree of Adoption (b) Biological Father ¨ Court Ordered Termination of Parental Rights; ¨ Death of Parent; ¨ Relinquishment by Biological Mother; or ¨ Decree of Adoption B. If an interstate placement was made, it was done in accordance with Federal, State and local laws and in compliance with the Interstate Compact on the Placement of Children or any other applicable state law regarding the interstate placement of children. ¨ Yes ¨ No

EXPENSES INCURRED BY ADOPTIVE PARENT(S) (Reimbursement shall not exceed $ 2,000.00. Attach verifying documents)
Expense	Amount	Expense	Amount
Attorney Fees	$	Adoption Agency Fees	$
Psychological Examination	$	Court Fees	$
Lodging (subject to State guidelines)	$	Meals (subject to State guidelines)	$
Birth Certificate	$	Mileage (subject to State guidelines)	$
Medical Examination	$	Other Adoption related expenses (specify. Use additional paper to list expenses, if necessary)	$
We (I) verify that the expenses listed above are reasonable and necessary adoption costs which were directly related to the legal adoption of the above named child with special needs. The reported expenses were incurred by the adoptive parent(s) and are not in violation of state or federal law. No reimbursement has been made from other sources or funds. We (I) claim reimbursement for the total amount of $________________in completing this adoption. _____________________________________________________________________________________________________________________ Signature of Adoptive Mother Social Security Number of Adoptive Mother Date __________________________________________________________________________________________________________ Signature of Adoptive Father Social Security Number of Adoptive Father Date Authorized Payee(s)_________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________
COUNTY OFFICE USE ONLY
I do affirm to the best of my knowledge that __________________________________ ¨ has ¨ has not met eligibility requirements and Name of Child ¨ has ¨ has not been determined as a child with “special needs”. _____________________________________________________________________________________________________________________ Signature of Social Worker Title _________________________________________________________________________________________________________ Adoption Agency Date
DISPOSITION OF REIMBURSEMENT CLAIM
¨ Approval of claim reimbursement ¨ Denial of claim reimbursement Reason for denial of claim reimbursement: ______________________________________________________________________ __________________________________________________________________________________________________________ ________________________________________________ ____________________________________ Signature of Agency Representative Date
FOR ADOPTIVE PARENT REIMBURSEMENT
MAIL COMPLETED FORM AND VERIFICATION DOCUMENTS TO: (Affix DSS Address Mailing Label or Complete Information) _______________________ Department of Social Services _________________________________________________ Mailing Address __________________________________________________ City State Zip Code

STATE OF NORTH CAROLINA

AGREEMENT FOR REIMBURSEMENT OF

NON-RECURRING ADOPTION COSTS

After receiving and approving the application for non-recurring costs, the following agreement has been entered into by the

_________________________________________ County Department of Social Services, hereafter called the Agency, and

_____________________________________________________________ for the purpose of facilitating the legal adoption of

^{Name of Adoptive Parent(s)}

________________________________________________. Born on ________________________________ and placed in the

^{Name of Adoptive Child Date of Birth}

adoptive home on _______________________________________________________________________________________

. ^{Date of Placement}

AMOUNT OF REIMBURSEMENT APPROVED
The amount of reimbursement has been determined through discussion and agreement between the Adoptive Parent(s) and the Agency. While not limited as to the number of items and services eligible for reimbursement, the total amount of reimbursement shall not exceed $ 2,000.00 and shall be provided to adoptive parent(s) and/or other designated individual(s) indicated on the application.
Expense	Amount
Attorney Fees	$
Psychological Examination	$
Lodging	$
Amended Birth Certificate	$
Medical Examination	$
Adoption Agency Fees	$
Court Fees	$
Meals	$
Mileage	$
Other Adoption related expenses (specify)	$
TOTAL REIMBURSEMENT	$
Signature of Adoptive Mother	Date
Signature of Adoptive Father	Date
Address of Adoptive Parent(s) (number, street, city, state, zip code)
Signature of Agency Director or Representative	Date

SPECIAL CHILDREN ADOPTION INCENTIVE FUND

REQUEST FOR PAYMENT

Department of Social Services responsible for Adoption Assistance: _______________________

Signature of Director or Designee: _________________________________________________

CHILD INFORMATION

SIS IDENTIFICATION NUMBER

LAST NAME

FIRST NAME

MI

PAYMENT AMOUNT OVER STANDARD ADOPTION ASSISTANCE RATE
EFFECTIVE DATE					MONTHLY AMOUNT
M	M	-	Y	Y

PAYEE INFORMATION

FIRST NAME

MI

LAST NAME

SOCIAL SECURITY NUMBER

-

-

ADDRESS

CITY

STATE

ZIP CODE

SUBMIT FORM TO: FAMILY SUPPORT AND CHILD WELFARE SERVICES

Foster Care/Adoption Policy Team

2409 Mail Service Center

Raleigh, NC 27699-2409

SPECIAL CHILDREN ADOPTION INCENTIVE FUND

SUPPLEMENTAL ADOPTION ASSISTANCE AGREEMENT

This Supplemental Adoption Assistance Agreement has been entered into by and between the _________________ County of Social Services, _____________________________________________,

^Address

(_____) _________ thereafter called the “Agency” and ____________________________________________

^{Telephone Number Adoptive Parents}

_____________________________________________________________________, ( ___ _)________________

^{Address Telephone Number}

hereafter caller the “Adoptive Parent(s)”, for the purpose of facilitating the adoption of _______________

^{Child’s First Name}

born on _______________________________, and to aid the adoptive family in providing proper care of this child.

I/We, the prospective adoptive parent(s), agree(s) that I/we intend to adopt ________________________

^{Child’s First Name}

and have signed this document prior to the finalization of the adoption so that this child can receive a supplemental payment from the Special Children Adoption Incentive Fund. I/We have already signed the regular Adoption Assistance Agreement on behalf of this child.

I/We agree(s) to accept payments from the Special Children Adoption Incentive Fund in the amount of

$ _________ per month as a supplement to the standard adoption assistance benefits.

I/We understand(s) that the Special Children Adoption Incentive Fund benefits are not an entitlement and are subject to the continuing availability of state and county funds.

*************************

I/We, the Adoptive Parent(s), and we, the Agency, have read, understand, and agree to the terms and provisions of this Supplemental Adoption Assistance Agreement.

_______________________________________________ ____________________________________

Adoptive Mother Date

_______________________________________________ ____________________________________

Adoptive Father Date

_______________________________________________ ____________________________________

Authorized Agency Director’s Signature Date

*************************

A signed copy of the Supplemental Adoption Assistance Agreement was given/sent to the adoptive parent(s) on _________________________________________________________________________________.

Date

SPECIAL CHILDREN ADOPTION INCENTIVE FUND

VERIFICATION OF CHILD’S NEED FOR DAILY SUPERVISION

I certify that I am a licensed health, mental health or developmental disability practitioner directly involved in the care of ____________________________________________________.

^{Name of Child}

This child has a health condition which requires eight or more hours of daily direct supervision from a foster parent, health professional and/or special education teacher to meet personal health needs or prevent self-destructive or assaultive behavior. The child’s daily supervision needs include the following:

___________________________________

^Signature

___________________________________

^{Position/Title}

___________________________________

^Date

SPECIAL CHILDREN ADOPTION INCENTIVE FUND

AGENCY VERIFICATION OF LEGAL CUSTODY AND

CHILD’S LIVING ARRANGEMENT FOR PAST SIX MONTHS

I, the undersigned declare that I am _____________________________________________of

Director of Social Services

_______________________________________Department of Social Services, and I verify that

_______________________________________ is in the legal custody and placement authority

Name of child for whom incentive fund will be made

of the ________________________________ Department of Social Services. I further verify

that the said child has resided in the licensed foster care home of

______________________________________________________________________________

Name of licensed foster parent(s)

______________________________________________________________________________

Mailing address of licensed foster parent(s)

______________________________________________________________________________

City State Zip Code

for the previous six consecutive months on a continuous basis and that the foster parent(s) have received monthly cash assistance from a governmental source in excess of the standard board rate established by the General Assembly for the previous six months on a continuous basis. The foster parent(s) have stated a willingness to adopt this child if the monthly cash assistance that they have received as foster parents is not terminated. The amount of monthly cash assistance above the standard board rate established by the General Assembly that is being received by the foster parent(s) is $ _____________.

This is the amount of monthly cash assistance the parent(s) will receive, subject to continuing legislative authorization, from the Special Children Adoption Incentive Fund above the standard board rate established by the General Assembly following the issuance of the Decree of Adoption.

___________________________________

^Signature

___________________________________

^Date

SPECIAL CHILDREN ADOPTION INCENTIVE FUND

VERIFICATION OF CHILD’S HEALTH CONDITION

I certify that the child, _________________________________________________, has the following health condition, and this health condition is expected to result in significant impairment in the child’s ability to function in the home, school or community and to endure throughout his/her childhood. The child’s health condition and resulting impairment are:

___________________________________

^{Physician’s Signature}

___________________________________

^Date

SECTION A. NOTIFICATION
TO: ADOPTIVE PARENT(S): ___________________________________________________________ Name(s) of Adoptive Parent(s)
ADOPTIVE PARENT(S) CURRENT ADDRESS
Mailing Address		City		State	Zip Code
County		Telephone Number ( )
We have been notified that your child(ren) will be living at the address below on ______________________________. Date
ADOPTIVE PARENT(S) NEW RESIDENCE ADDRESS
Mailing Address		City		State	Zip Code
County		Telephone Number ( )
CHILD A	First Name MI Last Name		Type of Adoption Assistance
			o IV-E o State Funded
CHILD B	First Name MI Last Name		Type of Adoption Assistance
			o IV-E o State Funded
CHILD C	First Name MI Last Name		Type of Adoption Assistance
			o IV-E o State Funded
FROM:	Compact Administrator’s Name Telephone Number
	Mailing Address
	City State Zip Code
	FAX Number Email Address
	Today’s Date
SECTION B STATUS OF NEW RESIDENCE STATE
New residence state O IS O IS NOT a member of the Interstate Compact on Adoption and Medical Assistance (ICAMA).

SECTION C CHILDREN RECEIVING IV-E ADOPTION ASSISTANCE

1. ICAMA Form 6.02 notifies you, the adoptive family, that this office has sent the necessary information to your new State of Residence informing it that your child(ren) is/are eligible to receive Medicaid in that State so that Medicaid Identification may be may be issued. 2. Contact your child(ren)’s new Residence State Adoption Compact Administrator named in Section D of the attached ICAMA Form 6.01 to determine what steps, if any, you need to take in order to receive a Medicaid Identification Card in your new State of Residence. 3. You may be instructed by the Compact Administrator to contact the Medicaid Office to obtain a new Medicaid Identification. You may be asked to complete an assignment of rights for medical support and payment. You may also be asked to provide other necessary information. You new Medicaid Office will also be able to provide you with information about the benefits available in the (new) residence State. 4. If you are moving to a State that is not a member of ICAMA as indicated above, you may need to go to your local Medicaid Office in the new State of residence with these forms to apply for Medicaid on behalf of your child(ren). If you encounter a problem, contact the Compact Administrator listed on this form.

SECTION D CHILDREN RECEIVING STATE-FUNDED ADOPTION ASSISTANCE

1. If your child is receiving state-funded adoption assistance as indicated in Section A of this form, then your child(ren) is/are not automatically eligible to receive Medicaid in the new State of Residence. 2. If you State of residence is a member of ICAMA as indicated in Section B of this form, then contact the Compact Administrator in the new State of residence as identified on Form 6.01. 3. If your new State of residence is not a member of ICAMA, you need to go to the local department of social services in the new State of Residence and inquire about receiving medical assistance. If you have questions, contact your state’s adoption assistance Compact Administrator as identified in FORM 6.01, Section D.

SECTION A CHILD(REN) IDENTIFYING INFORMATION

1. CHILD A

First Name MI Last Name

Birthdate MM DD YY

Social Security Number

Gender

Race

;

;

o Male

o Female

CHILD B

First Name MI Last Name

Birthdate MM DD YY

Social Security Number

Gender

Race

;

;

o Male

o Female

CHILD C

First Name MI Last Name

Birthdate MM DD YY

Social Security Number

Gender

Race

;

;

o Male

o Female

2. ADOPTIVE PARENT(S)

Father’s Name

Mother’s Name

3. ADOPTIVE PARENT(S) CURRENT ADDRESS

Mailing Address

City

State

Zip Code

County

Telephone Number ( )

4. ADOPTIVE PARENT(S) NEW RESIDENCE ADDRESS

Mailing Address

City

State

Zip Code

County

Telephone Number ( )

5. If child is not residing with adoptive parents, give reason :________________________ ____________________________________________________________________________________________________________________________________ __________________________________________________________________

6. BASIS OF MEDICAID ELIGIBILITY

CHILD A O Title IV-E/SSI O Title IV-E/AFDC O State Option CHILD B o Title IV-E/SSI o Title IV-E/AFDC o State Option CHILD C o Title IV-E/SSI o Title IV-E/AFDC o State Option

7. DATE OF MEDICAID CLOSURE (Last day of the month the child is living in the sending state.)

CHILD A

CHILD B

CHILD C

8. DATE REQUESTED FOR MEDICAID OPENING (First day of the month the child is living in the receiving state.)
CHILD A		CHILD B	CHILD C
SECTION B MEDICAID COVERAGE FOR STATE-FUNDED CHILDREN
1. The Adoption Assistance State o DOES o DOES NOT provide Medicaid to children with state-funded adoption assistance as an optional Medicaid group. 2. The Adoption Assistance State o DOES o DOES NOT provide Medicaid to children receiving state- funded adoption assistance from another ICAMA member state if the child was eligible to receive it in the adoption assistance state
SECTION C OTHER MEDICAL COVERAGE
1. Does child continue to be eligible for other medical assistance from the adoption assistance state?
CHILD A o Yes o No		CHILD B o Yes o No	CHILD C o Yes o No
2. Does child have other third party coverage through any program, organization, or person?
CHILD A O Yes o No o Unknown		CHILD B O Yes o No o Unknown	CHILD C O Yes o No o Unknown
3. List sources of medical coverage or benefits. CHILD A: O SSI O SSA O CHAMPUS O PRIVATE INSURANCE CHILD B: O SSI O SSA O CHAMPUS O PRIVATE INSURANCE CHILD C: O SSI O SSA O CHAMPUS O PRIVATE INSURANCE
SECTION D REFERRAL INFORMATION
FROM:	Compact Administrator’s Name Telephone Number
	Mailing Address City State Zip Code
	FAX Number Email Address
TO:	Compact Administrator’s Name Telephone Number
	Mailing Address City State Zip Code
	FAX Number Email Address
State Status: Current residence state O IS O IS NOT the Adoption Assistance state.
SECTION E CERTIFICATION
This is to certify that the records of my office show the above named child(ren) to be eligible for the Medicaid Identification document(s) in his/her/their new residence state in accordance with the information contained herein, the attached Adoption Assistance Agreement(s) and the Interstate Compact on Adoption and Medical Assistance. In addition, I hereby certify that the attached copy/ies of the most current Adoption Assistance Agreement(s)for the named child(ren) in the files of my office is/are true. Signed at _________________________________________ this ______day of ___________, _______ City State Month Year _________________________________________ _______________________________________ Signature Print Name ____________________________ _________________________________________ __________ Title Agency Date
Distribution: Send original with one (1) copy of current adoption assistance agreement to (new) Residence State, one (1) copy to adoptive parent(s) and one (1) file copy issuing office.

SECTION A SENDING INFORMATION

TODAY’S DATE:

FROM:

Compact Administrator’s Name Telephone Number

Mailing Address City State Zip Code

FAX Number Email Address

TO:

Compact Administrator’s Name Telephone Number

Mailing Address City State Zip Code

FAX Number Email Address

REASON(S) FOR REPORTING: (Check Appropriate Box(es) O Address Change O Adoption Status Change O Update on Medicaid Status O Change in Case Status

SECTION B CHILD(REN) IDENTIFYING INFORMATION

CHILD A

First Name MI Last Name

Birthdate MM DD YY

Social Security Number

;

;

CHILD B

First Name MI Last Name

Birthdate MM DD YY

Social Security Number

;

;

CHILD C

First Name MI Last Name

Birthdate MM DD YY

Social Security Number

;

;

ADOPTIVE PARENT(S)

Father’s Name

Mother’s Name

SECTION C CHANGE IN MEDICAID STATUS)

CHILD A

CHILD B

CHILD C

Medicaid Case Opened? o Yes o No

Medicaid Case Opened o Yes o No

Medicaid Case Opened o Yes o No

Medicaid Effective Date:

Medicaid Effective Date:

Medicaid Effective Date:

Medicaid Identification Number: (New residence State)

Medicaid Identification Number: (New residence State)

Medicaid Identification Number: (New residence State)

SECTION D CHANGE IN CASE STATUS)
CHILD A	CHILD B		CHILD C
Effective Date of Change:	Effective Date of Change:		Effective Date of Change:
o Active o Closed	o Active o Closed		o Active o Closed
Effective Date of Closing:	Effective Date of Closing:		Effective Date of Closing:
Reason for Closing case:	Reason for Closing case:		Reason for Closing case:
SECTION E CHANGE IN ADDRESS
Anticipated Moving date :
ADOPTIVE PARENT(S) CURRENT ADDRESS
Mailing Address		City		State	Zip Code
County		Telephone Number ( )
ADOPTIVE PARENT(S) NEW RESIDENCE ADDRESS
Mailing Address		City		State	Zip Code
County		Telephone Number ( )
SECTION F CHANGE IN ADOPTION STATUS
CHILD A	CHILD B		CHILD C
1. Effective Date of Change:	1. Effective Date of Change:		1. Effective Date of Change:
2. Adoption Assistance Agreement	Adoption Assistance Agreement		Adoption Assistance Agreement
(a) Adoption Assistance State:	(a) Adoption Assistance State:		(a) Adoption Assistance State::
(b) Original Agreement: Effective Date: Expiration Date:	(b) Original Agreement: Effective Date: Expiration Date:		(b) Original Agreement: Effective Date: Expiration Date:
(c) Current Agreement: Effective Date: Expiration Date:	(c) Current Agreement: Effective Date: Expiration Date:		(c) Current Agreement: Effective Date: Expiration Date:

3. Final Adoption Decree	Final Adoption Decree	Final Adoption Decree
CHILD A	CHILD B	CHILD C
Pending: o Yes o No	Pending: o Yes o No	Pending: O Yes o No
Date of Adoption Decree:	Date of Adoption Decree:	Date of Adoption Decree:
ICPC Notification made via 100B? o Yes o No	ICPC Notification made via 100B? O Yes o No	ICPC Notification made via 100B? O Yes o No
4. Adoption Terminated	Adoption Terminated	Adoption Terminated
CHILD A	CHILD B	CHILD C
Has Adoption terminated? o Yes o No	Has Adoption terminated? o Yes o No	Has Adoption terminated? O Yes o No
If “yes”, give date:	If “yes”, give date:	If “yes”, give date:

DISTRIBUTION: Prepare original and two (2) copies. Reporting state retains original one (1); recipient state retains one (1); and adoptive parent(s) receive(s) one (1).

Appendix I – DSS-5216 LINKS AUTHORIZATION FOR FUNDS ACCESS

AUTHORIZATION FOR FUNDS ACCESS

(LINKS Special Funds and Educational Training Vouchers)

I hereby certify that the following individuals meet the eligibility criteria to receive funding through the designated LINKS special funds, in accordance with the information outlined in policy.

___________________________________________

Social Work Supervisor, Date of signature

Name	Date of Birth	SIS ID	Housing funds	LINKS Transitional Funds	Educational Training Vouchers

Eligibility Criteria- Special Funds

Housing Funds (HOU)	LINKS Transitional Funds (LTF)	Educational/Training Vouchers (ETV)
1. Now between 18 and 21 (has not had 21st birthday), and 2. Was in DSS custody on 18th birthday and at that time was living in a licensed foster care living arrangement or was placed with a relative (not the removal home) or in other court-approved foster placement, and 3. Was not incarcerated in a correctional facility or other secure facility on 18th birthday.	1. Age 13 to 21 (has not had 21st birthday). 2. Financial assistance, combined with planned LINKS services, is needed to help the youth achieve one or more of the 7 program outcomes and has a reasonable chance of making a difference	1. Was in DSS custody on or after 17th birthday and at that time was living in a licensed foster care living arrangement or was placed with a relative (not the removal home) or in other court-approved foster placement or 2. was adopted from DSS foster care after 16th birthday, and 3. is now under the age of 21 (has not had 21st birthday) and has been accepted for enrollment in a qualifying postsecondary educational or vocational training program. 4. If enrolled in a qualifying postsecondary program, is making satisfactory progress toward completion of the course of study. Note: All ETV expenditures are handled directly through the ETV Contractor.

REQUEST FOR REIMBURSEMENT

LINKS SPECIAL FUNDS

Please reimburse (Total amount due) _________________ to the __________________ County Department of Social Services for funds spent on behalf of the following individuals. I certify that the individuals listed below are 1) eligible under the guidelines specified by the LINKS program; 2) were pre-authorized for access and 3) that expenditures for which reimbursement is claimed were allowable and appropriate according to LINKS policy.

Certified by _______________________________________, Position ______________________________________________ Date __________________

PLEASE PRINT INFORMATION CLEARLY

			HOU	LTF
NAME	DOB	SIS ID	Housing Rent, rent deposits, room and board, or down payments on dwellings for aged out young adults 18 to 21 (up to $1000)	LINKS Transitional Funds Reimbursement for expenditures directly related to achievement of LINKS positive outcomes. Ages 13 to 21. (up to $2250)	Purpose of Expenditure/Outcome (required for reimbursement) and outcome goal # 1. Economic self-sufficiency 2. Safe and stable place to live 3. Academic/vocational preparation 4. Personal support network of 5+ caring adults 5. Avoidance of high risk behaviors 6. Postponed parenthood 7. Access to needed health care