SR 11-40 Dated 10/11

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases:

·   revised DFA Form 800Q, Assisted Application for Help With Medicare Costs Through the Medicare Savings Program, and its associated instructions; and

·   the obsolescence of the following forms and their associated instructions:

-   DFA Form 768, Recoupment Referral; and

-   DFA Form 769, Alien Sponsor Affidavit on Non-Support.

DESCRIPTION OF REVISIONS MADE TO FORMS

The following changes have been made to DFA Form 800Q which is only used by certain ServiceLink-assisted individuals and New Hampshire Housing Authority (NHHA) residents to apply for the following programs grouped under the umbrella term "Medicare Savings Program:" the Qualified Medicare Beneficiary (QMB), Specified Low Income Medicare Beneficiary (SLMB), Specified Low Income Medicare Beneficiary at 135% of federal poverty income guidelines (SLMB135), and Qualified Disabled Working Individual (QDWI) programs:

·   The form was renamed Assisted Application for Help With Medicare Costs Through the Medicare Savings Program.

·   References to SLMB175 were removed as this program ended January 2003 (see SR 03-04, dated January 2003, for more details).

·   References to "fair hearing" were replaced with "administrative appeal."

·   The language was simplified throughout the form to bring it closer to an 8th grade reading level.

·   The Rights and Responsibilities page of DFA Form 800Q was updated to align with recent changes made to DFA Form 811R, Application: Your Rights and Responsibilities.

·   The statement of understanding referring to reimbursement claims for anyone age 55 or older was eliminated from the form based on policy released in SR 02-42, dated August 2002.

·   The following statement was added to the last page of the Form to better align with IRS computer matching requirements:

I UNDERSTAND that DHHS will contact other people or organizations to get additional proofs of my eligibility, that the information I have provided will be used in computer matching with other agencies, and that information from the matching programs may be used to determine or redetermine eligibility for and/or amount of my benefits.

·   In the "Medical Insurance" section of the form, Medicare Part D was added to the list of possible insurance that a household member might have.

·   A field was added to the form to collect the applicant’s email address. This addition is associated with the statewide implementation of NH EASY (see DFA SR 11-09, dated January 2011, for more information).

The instructions for DFA Form 800Q were updated as needed to incorporate the statements above. Additionally, references in the instructions to "Health Insurance Counseling, Education, and Assistance Services (HICEAS)" were replaced with "ServiceLink," which is a statewide network of community-based resources for seniors, adults living with disabilities, and their families.

The standing stock of current and older versions of DFA Form 800Q must be used until the stock has been depleted, at which point the DHHS Warehouse may be contacted in the usual manner, via the Quarterly Forms Order (QFO), for additional supplies. The new version of DFA Form 800Q will be printed once the current supply of the form has been exhausted.

Forms Obsoletion

The following forms and their associated instructions are obsolete with the release of this SR:

·   DFA Form 768, Recoupment Referral: This form is not needed to refer adult category financial assistance recipients who have received overpayments, and subsequently will be involved in Department efforts to recoup the overpayments, to the Bureau of Elderly and Adult Services (BEAS), the Community Mental Health Agency, or Area Agencies. As such, Adult Assistance Manual (AAM) PART 631, RECOUPMENT OF FINANCIAL ASSISTANCE, was updated accordingly.

·   DFA Form 769, Alien Sponsor Affidavit on Non-Support: This Form has never been used so is obsolete with the release of this SR. Family Assistance Manual (FAM) 305.07, Ineligible Sponsored Noncitizens, has been rewritten to replace the reference to Form 769 with the specific information that is needed on the sponsor’s affidavit when the noncitizen is requesting Department assistance during the initial 3-year period of ineligibility. Text has been additionally revised to better align with policy in He-W 616.01(a).

POLICY MANUAL REVISIONS

Revised Adult Assistance Manual Topics

PART 109  APPLICATION PROCESS

Section 109.01  Filing an Application

Section 109.03  Processing a Filed Application

PART 121  INTERVIEWS

Section 155.01  Timely Notice

PART 631  RECOUPMENT OF FINANCIAL ASSISTANCE

Revised Family Assistance Manual Topics

Section 305.07  Ineligible Sponsored Noncitizens

IMPLEMENTATION

District Offices, ServiceLink, and the New Hampshire Housing Authority (NHHA) are to continue to use the old versions of DFA Form 800Q until their supply is exhausted. The new version of DFA Form 800Q will be printed when the current supply is depleted; it is also electronically available to DHHS staff via the Lotus Notes Family Services Database.

The forms obsoleted by this SR may be recycled upon receipt of this SR. A Certificate of Destruction has been included in this SR.

CLIENT NOTIFICATION

No client notification is planned or needed.

TRAINING

No special training is planned or needed.

FORMS MANUAL POSTING INSTRUCTIONS

DISPOSITION

This SR may be destroyed or deleted after its contents have been noted and the revised manual topics released by this SR have been posted to the On-line manuals.

DISTRIBUTION

This SR will be distributed according to the electronic distribution list for Division of Family Assistance policy releases. This SR, and revised On-Line Manuals, will be available for agency staff in the On-Line Manual Library, and for public access on the Internet at www.dhhs.nh.gov/DFA/publications.htm, effective December 5, 2011. Additionally, this SR, and printed pages with posting instructions, will be distributed under separate cover to all internal hard copy holders of the Adult Assistance, Family Assistance, and Forms Manuals.

DFA/JBV:s