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A. Explain to the applicant that most individuals who are eligible for Work First Family Assistance are concurrently eligible for Medicaid. The caseworker must ask the applicant if there are individuals in the household who only want to apply for Medicaid. Document the applicant’s decision of whether or not to apply for Medicaid for those individuals. Inform the applicant that if any family members are not eligible for WFFA, the DSS worker will separately evaluate their eligibility for Medicaid. Document in the case record the Medicaid eligibility of any individuals who are not eligible for WFFA and the applicant’s decision whether or not to apply for Medicaid for those individuals.
1. Explain to the applicant that the effective date of Medicaid coverage can be as much as three months prior to the month of application if:
a. The applicant has a medical need during that time; and
b. The family met the requirements for Work First Family Assistance during the retroactive month(s).
2. Document whether the applicant expresses a need for retroactive Medicaid.
3. If it appears the applicant may not meet the categorical requirements for Work First Family Assistance during the retroactive period, evaluate each family member’s eligibility for Medicaid under other program categories.
Explain to the applicant that Medicaid coverage for emergency medical services may be available to non qualified immigrants or qualified immigrants during their 5 year disqualification period. Document whether the applicant expresses a need for Emergency Medicaid.
Explain that:
1. A Medicaid card is issued yearly. If a year passes without the recipient receiving a replacement Medicaid ID card due to loss, change of primary care provider, etc. a new card will be issued. The Medicaid card is used in the same manner as private insurance cards. It provides a lead to a medical provider that the patient may be covered by Medicaid, and that eligibility must be verified.
2. It is the recipient's responsibility to show the Medicaid ID Card at the time a medical service is provided so the medical provider (doctor, pharmacy, hospital, etc.) can bill Medicaid for his services.
a. If the recipient does not provide their Medicaid ID card at the time of the service, the provider can bill the recipient for the service.
b. Once the provider agrees to accept the recipient as a Medicaid patient and verifies coverage, the provider must accept any co-payment and payment from Medicaid as payment in full.
c. A small fee (co-payment) may be charged for some services covered by Medicaid. This fee does not apply to:
(1) Children under age 21;
(2) People in nursing homes; or
(3) Women receiving pregnancy related services.
d. If a service is not covered by Medicaid, the provider should tell the recipient before the service is provided.
3. If retroactive coverage is authorized, the recipient must inform the provider(s), where there is an unpaid bill, of the retroactive months of eligibility and provide a copy of the Medicaid card. If the recipient does not inform the provider(s) of Medicaid eligibility to allow the provider(s) to bill Medicaid within the 365 day billing time limit, the recipient will be responsible for paying the bills.
4. Unless exempt, recipients must enroll with a Primary Care Provider who participates in Community Care North Carolina/Carolina Access Managed Care program.
5. Non-Medicaid covered services will be charged to the recipient. An example is non-approved eyeglass frames.
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For questions or clarification on any of the policy contained in these manuals, please contact your local county office. |
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