SR 12-04 Dated 07/12

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases policy changes to the medical assistance program for children up to age 19. On June 30, 2012 the contract with New Hampshire Healthy Kids Corporation (NHHKC) will end, resulting in the following policy changes effective July 1, 2012:

·   The "Healthy Kids Silver" program will be absorbed into New Hampshire’s Medicaid program; and

·   New Hampshire’s Medicaid program for children under the age of 19 will be called Children’s Medicaid.

Implementation of the new policy required the following changes:

·   removing the term "Healthy Kids" and all variations thereof, from all Department materials;

·   the renaming of District Office #78 from "Central Healthy Kids" to the Children’s Medicaid Unit (CMU);

·   the relocation of DO #78 from Pillsbury Street in Concord to the Main Building on 105 Pleasant Street in Concord;

·   distribution of NH Medicaid cards to all children who currently hold a "Healthy Kids" card and are eligible to receive Children’s Medicaid; and

·   discontinuance of any association with Harvard Pilgrim Health Care or Northeast Delta Dental.

The following forms also required revisions:

·   DFA Form 77U, It Takes a Village, and its associated Bosnian and Spanish translations, DFA Form 77U(Bo) and DFA Form 77U(Sp);

·   DFA Form 125, Transfer of Client Records;

·   DFA Form 215, Reporting Requirements Handout, and its associated Bosnian and Spanish translations, DFA Form 215(Bo) and DFA Form 215(Sp);

·   DFA Form 470, Food Stamp Program Change Report Form, and its associated Bosnian and Spanish translations, DFA Form 470(Bo) and DFA Form 470(Sp);

·   DFA Form 757, How Your Benefits Will Change When You Go to Work!, and its associated Bosnian and Spanish translations, DFA Form 757(Bo) and DFA Form 757(Sp);

·   DFA Form 800, Application for Assistance, and its associated Bosnian and Spanish translations, DFA Form 800(Bo) and DFA Form 800(Sp);

·   DFA Form 800A, DFA Programs & Services Guide, and its associated Bosnian and Spanish translations, DFA Form 800A(Bo) and DFA Form 800A(Sp);

·   DFA Form 800P, Application for Children’s Medicaid (CM) and Medical Coverage for Pregnant Women (MCPW), its associated instructions, and its associated Bosnian and Spanish translations, DFA Form 800P(Bo) and DFA Form 800P(Sp);

·   DFA Form 800PEN, Notice of Presumptive Eligibility Decision for Children’s Medicaid (CM) and Medical Coverage for Pregnant Women (MCPW), and its associated instructions;

·   DFA Form 800PR, Renewal Application For Children’s Medicaid (CM) and Medical Coverage for Pregnant Women (MCPW), its associated instructions, and its associated Bosnian and Spanish translations, DFA Form 800PR(Bo) and DFA Form 800PR(Sp);

·   DFA Form 808P, Information Necessary to Support Your Medical Coverage Application, and its associated instructions;

·   DFA Form 810, Notice of Rights and Responsibilities, and its associated Bosnian and Spanish translations, DFA Forms 810(Bo) and DFA Form 810(Sp);

·   DFA Form 811R, Application: Your Rights and Responsibilities, and its associated Bosnian and Spanish translations, DFA Form 811R(Bo) and DFA Form 811R(Sp);

·   DFA Form 811S, Application: Statements of Understanding, and its associated Bosnian and Spanish translations, DFA Form 811S(Bo) and DFA Form 811S(Sp); and

·   Food Stamp 130% Reporting Requirements Poster.

BACKGROUND

During the 2011 legislative budget session, HB2 (Chapter 224:43, Laws of New Hampshire 2011), amended RSA 126-A:3,VIII and transferred the responsibility for administration of New Hampshire’s children’s health insurance program (CHIP) from New Hampshire Healthy Kids Corporation (NHHKC) to DHHS. As required by RSA 126-A:3,VIII, DHHS reviewed program models allowable under 42 U.S.C 1397aa, and determined that the program that best demonstrated the greatest efficiency and value was a full Medicaid expansion program.

Prior to July 1, 2012, New Hampshire’s CHIP program was considered a ‘combination program’ because it utilized both a Medicaid expansion program, and a separate third party health plan. Under the new, full Medicaid expansion program, those children formerly eligible under "Healthy Kids Silver" have been moved into the Medicaid expansion program. These children will now receive all services available under the Title XIX Medicaid state plan, and will be subject to all Title XIX Medicaid program requirements.

POLICY

Prior to July 1, only the "Healthy Kids Gold" program was administered under New Hampshire Medicaid. As of July 1, the "HKS" program is obsolete and the former "Healthy Kids Gold" and "Healthy Kids Silver" programs will be combined into one program called Children’s Medicaid (CM), and will be administered under New Hampshire’s Medicaid program. CM is available for eligible children up to age 19 with family income less than or equal to 300% of the Federal Poverty Income Guidelines (FPG). Eligibility requirements, benefits, and services offered via CM remain essentially the same as the "Healthy Kids Gold" program:

·   no premiums or co-pays will be required;

·   retroactive medical assistance will be available; and

·   presumptive eligibility will be available.

All applicants and recipients for CM:

·   must be permitted to have other medical insurance, however information on medical insurance outside of Medicaid must be provided to the Department, as is required with all other Medicaid programs;

·   must provide their SSN as a condition of eligibility; and

·   must receive their medical and dental services from doctors and providers enrolled in NH Medicaid.

Implementation of the new policy required the following changes:

·   removing the term "Healthy Kids" and all variations thereof, from all Department materials;

·   the renaming of District Office #78 from "Central Healthy Kids" to the Children’s Medicaid Unit (CMU);

·   the relocation of DO #78 from Pillsbury Street in Concord to the Main Building on 105 Pleasant Street in Concord;

·   distribution of NH Medicaid cards to all children who currently hold a "Healthy Kids" card and are eligible to receive Children’s Medicaid; and

·   discontinuance of any association with Harvard Pilgrim Health Care or Northeast Delta Dental.

Additionally, the following forms required revisions:

·   DFA Form 77U, It Takes a Village, and its associated Bosnian and Spanish translations, DFA Form 77U(Bo) and DFA Form 77U(Sp);

·   DFA Form 125, Transfer of Client Records;

·   DFA Form 215, Reporting Requirements Handout, and its associated Bosnian and Spanish translations, DFA Form 215(Bo) and DFA Form 215(Sp);

·   DFA Form 470, Food Stamp Program Change Report Form, and its associated Bosnian and Spanish translations, DFA Form 470(Bo) and DFA Form 470(Sp);

·   DFA Form 757, How Your Benefits Will Change When You Go to Work!, and its associated Bosnian and Spanish translations, DFA Form 757(Bo) and DFA Form 757(Sp);

·   DFA Form 800, Application for Assistance, and its associated Bosnian and Spanish translations, DFA Form 800(Bo) and DFA Form 800(Sp);

·   DFA Form 800A, DFA Programs & Services Guide, and its associated Bosnian and Spanish translations, DFA Form 800A(Bo) and DFA Form 800A(Sp);

·   DFA Form 800P, Application for Children’s Medicaid (CM) and Medical Coverage for Pregnant Women (MCPW), its associated instructions, and its associated Bosnian and Spanish translations, DFA Form 800P(Bo) and DFA Form 800P(Sp);

·   DFA Form 800PEN, Notice of Presumptive Eligibility Decision for Children’s Medicaid (CM) and Medical Coverage for Pregnant Women (MCPW), and its associated instructions;

·   DFA Form 800PR, Renewal Application For Children’s Medicaid (CM) and Medical Coverage for Pregnant Women (MCPW), its associated instructions, and its associated Bosnian and Spanish translations, DFA Form 800PR(Bo) and DFA Form 800PR(Sp);

·   DFA Form 808P, Information Necessary to Support Your Medical Coverage Application, and its associated instructions;

·   DFA Form 810, Notice of Rights and Responsibilities, and its associated Bosnian and Spanish translations, DFA Forms 810(Bo) and DFA Form 810(Sp);

·   DFA Form 811R, Application: Your Rights and Responsibilities, and its associated Bosnian and Spanish translations, DFA Form 811R(Bo) and DFA Form 811R(Sp);

·   DFA Form 811S, Application: Statements of Understanding, and its associated Bosnian and Spanish translations, DFA Form 811S(Bo) and DFA Form 811S(Sp); and

·   Food Stamp 130% Reporting Requirements Poster.

All offices were given instructions to recycle any copies of the forms listed above in their possession, and were provided with a small supply of the new versions to begin using upon receipt. A Certificate of Destruction has been included with this SR.

NEW HEIGHTS SYSTEMS PROCEDURES

All changes described in this SR will be automated in New HEIGHTS and NH EASY as follows:

·   On May 22, 2012, the category of Infants Expanded was changed to Children’s Expanded and the age requirements were changed from "zero to one", to "zero to 19," after which all applicants and recipients with gross family income >185% but =300% of the FPG will be categorized in New HEIGHTS as "Children’s Expanded". All Children’s Medicaid applicants and recipients with gross family income =185% will continue to be categorized in New HEIGHTS as "PLC." These categories are different for funding purposes only. Medical assistance under these two categories will be referred to solely as Children’s Medicaid as all program requirements are the same. All NODs created will show the child being open for the new umbrella name of Children’s Medicaid or CM. On this date, New HEIGHTS additionally changed the name of DO #78 to the Children’s Medicaid Unit (CMU).

·   As of June 1, the new local phone number for the CMU will be active and will be listed on NODs received after that date.

·   On June 6, 2012, a mass change was run to move open/pending "Healthy Kids Silver" category children out of CHIP and into Medicaid. Because these children will have income in excess of 185% of FPG, they will cascade to Children’s Expanded unless the case experienced other changes in the household’s income at the same time which render them eligible for PLC, eligible for In and Out CM, or ineligible for Medicaid.

Additionally, New HEIGHTS made text changes to the following New HEIGHTS-generated letters to remove references to "Healthy Kids:"

·   CM0016, CSD- HC-CSD ltr;

·   CM0026, Go Green Confirmation Letter; and

·   AE0013, Child Support Good Cause Decision.

The revised New HEIGHTS-generated letters were released by New HEIGHTS under separate cover on May 29, 2012.

DESCRIPTION OF REVISIONS MADE TO FORMS

In general, all of the forms described below were altered to remove references to "Healthy Kids" or its derivatives, such as "Healthy Kids Gold", "Healthy Kids Silver", "HKG," "HKS," or references to "NH Healthy Kids Corporation." These terms were replaced by Children’s Medicaid (CM) and the Children’s Medicaid Unit (CMU), if appropriate. Additional alterations have been listed as follows and were the result of feedback from Field Operations, Staff at DO #78, Bureau of Elderly and Adult Services (BEAS), the EBT unit, and the Child Development Bureau (CDB):

·   DFA Form 77U, It Takes a Village, and its associated Bosnian and Spanish translations, DFA Form 77U(Bo) and DFA Form 77U(Sp), were revised to remove a reference to the "Healthy Kids" program. There are no changes in the way this form will be used, so the instructions for this form were not altered and will not be re-released with this SR.

·   DFA Form 125, Transfer of Client Records, was revised to replace "NHHK District Office" with "CMU District Office" as an option from the menu list in the "From" and "To" fields on this electronic form. This form is still used to transfer paper case files because certain cases, such as long-term cases, can not utilize the Document Imaging process and must remain in paper format. Because the manner in which this form is used remains unchanged, no changes were made to the instructions for this form at this time. Offices can detach this electronic form from the email releasing the SR and save it into the District Office templates folder on the shared drive. The new version can be used immediately upon receipt.

·   DFA Form 215, Reporting Requirements Handout, and its associated Bosnian and Spanish translations, DFA Form 215(Bo) and DFA Form 215(Sp), were revised to remove a reference to "Healthy Kids" medical assistance. There are no changes in the way this form will be used, so the instructions for this form were not altered and will not be re-released with this SR;

·   DFA Form 470, Food Stamp Program Change Report Form, and its associated Bosnian and Spanish translations, DFA Form 470(Bo) and DFA Form 470(Sp), were revised to remove a reference to "Healthy Kids" medical assistance. There are no changes in the way this form will be used, so the instructions for this form were not altered and will not be re-released with this SR;

·   DFA Form 757, How Your Benefits Will Change When You Go to Work!, and its associated Bosnian and Spanish translations, DFA Form 757(Bo) and DFA Form 757(Sp), were revised to:

- replace references to the "Healthy Kids" program with the term Children’s Medicaid (CM) and update the website where information about CM can be found.

- remove a reference to case management offered through the New Hampshire Employment Program (NHEP) as this is no longer offered;

- provide updated website information for the Earned Income Tax Credit (EITC) program; and

- update DFA Client Services’ phone number to reflect that it is now 1-800-852-3345 ext. 9700.

There are no changes in the way this form will be used, so the instructions for this form were not altered and will not be re-released with this SR.

·   DFA Form 800, Application for Assistance, and its associated Bosnian and Spanish translations, DFA Form 800(Bo) and DFA Form 800(Sp), were revised as follows:

- references to the "Healthy Kids" program were replaced with the term Children’s Medicaid (CM), as needed;

- in Section C of the actual application, the type of assistance category of "Home and Community-Based Care (HCBC)/Nursing Facility (NF) Services" was split so that each type of assistance, HCBC and NF, now have a check-off box. This alteration was at the request of BEAS and will help them determine the scheduling of medical reviews;

- an editing change was made to the "Agency Use Only" box on the first page of the application to remove the "CR" preceeding "Case #" as this text was redundant and confusing. "HKG/HKS" was also replaced with CM in this box;

- child care text, either in association with the assistance received or in regards to providers, was added at the request of CDB to the "Quality Control," "Reporting Changes," and "Attention" sections of the Rights and Responsibilities pages of DFA Form 800. CDB also requested the following new addition to the "Do Not" section: Do not use child care services paid for by DHHS, for employment-related activities not approved by DHHS;

- the Electronic Benefit Transfer (EBT) unit requested the following new addition to the "Do Not" section of the Rights and Responsibilities page of DFA Form 800: Do not give your EBT Card PIN out to anyone;

- CDB also requested the following new addition to the Statements of Understanding page of DFA Form 800: I understand that I must only use child care services paid for by DHHS for those employment-related activities approved by DHHS. I may have to reimburse DHHS for those payments made for times I was involved in other, non-approved activities; and

- the Form 800 was greatly reformatted as well to help in this current transition: The application is no longer printed on cream colored paper with blue ink. Instead it will be printed on white paper with black ink, and the headers for each section will be bright green.

There are no changes in the way this form will be used, so the instructions for this form were not altered and will not be re-released with this SR.

·   DFA Form 800A, DFA Programs & Services Guide, and its associated Bosnian and Spanish translations, DFA Form 800A(Bo) and DFA Form 800A(Sp), were revised as follows:

- references to the "Healthy Kids" program were replaced with the term Children’s Medicaid (CM). Text was also revised in the CM section to reflect the age ranges of the program and that it’s free medical coverage for eligible families Additionally, text in the "How Are Benefits Delivered? Medical Assistance" section was reworked to reflect that HKS will no longer receive a special Medical card from a contracted insurance carrier. Now that the insurance will be provided under Medicaid, a regular Medicaid card will be provided;

- the NH EASY website was added to the front cover to alert readers that applications for assistance can be conducted online;

- the elderly and disabled resource limit in the Food Stamp program section was revised to reflect the new limit of $3,500. See DFA SR 12-11 for details;

- the text in the Medical Coverage for Pregnant Woman (MCPW) section was edited to reflect that it’s free medical coverage;

- a reference to the Qualified Disabled and Working Individual (QDWI) program was added to the Medicare Savings Program (MSP) section, and the QDWI resource limit was listed; and

- text in the "How Are Benefits Delivered? EFT or EBT" section was reworked to reflect that recipients of cash assistance benefits have a choice between EFT or EBT for the method by which their cash benefit will be issued. See DFA SR 12-19 for details.

There are no changes in the way this form will be used, so the instructions for this form were not altered and will not be re-released with this SR. The Spanish and Bosnian versions are being retranslated and will be released under separate cover.

·   DFA Form 800P, Application for Children’s Medicaid (CM) and Medical Coverage for Pregnant Women (MCPW), and its associated Bosnian and Spanish translations, DFA Form 800P(Bo) and DFA Form 800P(Sp), were greatly revised as follows:

- the new version of the form has been completely reformatted. The previous version had been created by "NHHKC" consultants in QUARK, a software that DHHS did not have. As such, during the revisions, the form had to be recreated using Word. That process did not allow the same fonts, pictures, or coloring to be used. Because of this, and to help in the transition, this form is no longer printed on white paper with shades of blue for text, pictures, and headers. Instead it will be printed on white paper with black ink, and the headers for each section will be a bright yellowy orange;

- throughout the form, references to the "Healthy Kids" program were replaced with the term Children’s Medicaid (CM) and the title of the form was changed accordingly;

- text was added on the front page of the application to notify individuals who are interested in applying for CM/MCPW that they may also be eligible for other programs of assistance offered by DFA. Because DFA Form 800P cannot be used to apply for these other programs of assistance, text has been added to list the ways that application for these other programs can occur, this included adding the NH EASY and DFA web addresses;

- applicant reference information that was formerly printed on the last pages of the old version of DFA Form 800P has been moved to the beginning of the application to ensure that the information is situated on pages that can be torn off and retained by the applicant. Specifically, text related to "Your Rights," "Social Security Numbers," and "Citizenship and Identity" was moved to the beginning of the application. Text about income that had been provided on the old version of DFA Form 800P was eliminated from the new version of the form, as this information is adequately discussed in the "Proofs" section. A new text section, however, entitled "Your Responsibilities," was added to this applicant reference page to ensure that applicants receive information about reporting changes, verification requirements, paying back benefits received in error, assignment to DHHS of the applicant’s rights to all third party insurance or medical payments, and that the applicant’s case may be chosen for a quality control or other governmental review and the applicant’s responsibilities for assisting in these reviews;

- the proofs page that was formerly printed as the last page of the old version of DFA Form 800P was moved to the front section of the new version of the application. This text was additionally edited to eliminate the large amount of text devoted to the documentation required to prove citizenship and identity. Changes at the federal level and implementation of the Social Security Administration cross-match in August 2010 removes the burden on most applicants to provide original paper proof of citizenship and identity as a condition of eligibility for medical assistance. See SR 10-31 for more details;

- a Date of Birth field was added to the "Tell Us Who You Are and Where You Live" section. Additionally, a field to collect the individual’s email address and a question about whether the individual would like to Go Green was added to this section. These additions were requested by staff in the CMU, DFA Field Operations, and to support the statewide implementation of NH EASY (see DFA SR 10-31 for more details);

- in the section collecting information about each child living in the home under age 19, a field to collect the child’s grade level in school was added. Date of Birth fields were added to the section collecting information about the child’s parents, and a marital status question was added. Parental information has been eliminated from the Child 2 & 3 sections. This section also now only collects information for 3 children, rather than 4, as the average CM household does not contain 4 children. Households containing 4 or more children may provide the needed information on a separate sheet of paper and attach it to the application. These additions were requested by staff in the CMU and DFA Field Operations;

- the section collecting information about pregnant women now follows the sections collecting information on the children in the household. This section was additionally revised to request the date of birth of the woman who is pregnant, request information about whether the pregnant woman is a student and, if so, what grade, and, if the pregnant woman is married, request information about if the husband lives in the home and the husband’s date of birth. The field requesting the pregnant woman’s SSN was removed from this section as this information has generally been provided in the first section. If the information is not provided because the person completing the first section of the application is not the pregnant woman, CMU workers will contact the household to get the pregnant woman’s SSN. These revisions were requested by staff in the CMU and DFA Field Operations;

- in the section collecting information about other income, a field to collect the state from which Unemployment Income is being provided was added. A field to collect the claim number was added for Social Security income, and the following text was added after the "Other Income" field to help explain what is meant by "other" income: (such as interest/dividends/trusts). These revisions were requested by staff in the CMU and DFA Field Operations;

- the child/adult care expenses was revised to remove reference to adult care expenses, and specify that expenses for children are for legal dependents;

- text in the section collecting information about whether the applicant would like help with unpaid medical bills was slightly expanded to better collect information about whether the applicant would also like to apply for retroactive medical assistance;

- the "Tell Us About Health Insurance" section was moved from the beginning sections of the application to near the end of the application. Additionally, the time period for requesting information associated with past health insurance coverage was changed from 6 months to 3 months. Although prior health insurance coverage will no longer prevent an applicant’s eligibility for CM, DFA still needs to know about other health insurance coverage for third party liability, as all available parties must be billed and all resulting payments must be applied to the cost of medical care before DHHS will pay. However, DFA now only needs to know about health coverage in the preceding 3 months, which is the eligibility period for retroactive medical coverage. This section was also expanded to ask the applicant why the insurance coverage ended, if the medical assistance received was from another state, and, if so, which state. Most of these revisions were requested by staff in the CMU and DFA Field Operations; and

- the signature statements and "application assistor" box (related to presumptive eligibility) were moved to the last page of the application. Additionally, the following statement was added to the "I understand" statements preceding the field for the applicant’s signature: If I choose to Go Green, I understand that this means that I will get future notifications from DFA through my NH EASY account, and I will no longer get paper notices. DFA will email me when I have these notices using the email address I gave above. This text was added to support the addition of the "Go Green" question at the beginning of the application and the statewide implementation of NH EASY (see DFA SR 11-09 for more details).

The instructions for this form were updated accordingly.

·   Electronic DFA Form 800PEN, Notice of Presumptive Eligibility Decision for Children’s Medicaid (CM) and Medical Coverage for Pregnant Women (MCPW), was revised as follows:

- references to the "Healthy Kids" program were replaced with the term Children’s Medicaid (CM); and

- text on the form was additionally altered to reflect that pharmacists may not call First Health/Magellan to obtain a Medicaid Identification (MID) number as that is not included in their scope of work, per DHHS’ contract. However, the pharmacist may call HP to obtain eligibility information and to get the MID number.

The instructions for this form were updated accordingly. Since this form is only used by PE providers, the Supervisor of the CMU District Office has been provided with the new version of this electronic form and will be sending it to all our PE providers to be used immediately upon receipt.

·   DFA Form 800PR, Renewal Application For Children’s Medicaid (CM) and Medical Coverage for Pregnant Women (MCPW), and its associated Bosnian and Spanish translations, DFA Form 800PR(Bo) and DFA Form 800PR(Sp), were greatly revised as follows:

- the new version of the form has been completely reformatted. The previous version had been created by NHHKC consultants in QUARK, a software that DHHS did not have. As such, during the revisions, the form had to be recreated using Word. That process did not allow the same fonts to be used. Because of this, and because there is no stock of lavender paper so the form must always be "sprayed" with ink to achieve a lavender hue, which is costly, this form will instead be printed on white paper with black ink, and the headers for each section will be lavender;

- throughout the form, references to the "Healthy Kids" program were replaced with the term Children’s Medicaid (CM) and the title of the form was changed accordingly;

- text was added on the front page of the Form 800PR to remind individuals who are renewing their CM/MCPW coverage that they may also be eligible for other programs of assistance offered by DFA. Because DFA Form 800PR cannot be used to apply for these other programs of assistance, text has been added to list the ways that application for these other programs can occur, this included adding the NH EASY and DFA web addresses;

- to encourage the return of DFA Form 800PR earlier and help prevent recipients from losing eligibility and/or experiencing a delay in receipt of benefits to which they are entitled and eligible, text only was changed from "the 15th of next month" for returning the DFA Form 800PR and associated required proofs to "the 10th of next month." Policy does not change. Medical assistance recipients still have until the 15th of the last month of their redetermination period to complete the redetermination process, per Family Assistance Manual (FAM) 161.05, Processing Redeteminations/Recertifications;

- recipient reference information that was formerly printed on the last pages of the old version of DFA Form 800PR has been moved to the beginning of the form to ensure that the information is situated on pages that can be torn off and retained by the recipient. Specifically, text related to "Your Rights," "Social Security Numbers," and "Citizenship and Identity" was moved to the beginning of the Form 800PR. Text about income that had been provided on the old version of DFA Form 800PR was eliminated from the new version of the form, as this information is adequately discussed in the "Proofs" section. A new text section, however, entitled "Your Responsibilities," was added to this reference page to ensure that recipients continue to receive information about reporting changes, verification requirements, paying back benefits received in error, assignment to DHHS of the recipient’s rights to all third party insurance or medical payments, and that the recipient’s case may be chosen for a quality control or other governmental review and the recipient’s responsibilities for assisting in these reviews;

- the proofs page that was formerly printed as the last page of the old version of DFA Form 800PR was moved to the front section of the new version of the form;

- a Date of Birth field was added to the "Tell Us Who You Are and Where You Live" section. Additionally, a field to collect the individual’s email address and a question about whether the individual would like to Go Green was added to this section. These additions were requested by staff in the CMU, DFA Field Operations, and to support the statewide implementation of NH EASY (see DFA SR 10-31 for more details);

- in the section collecting information about each child living in the home under age 19, a field to collect the child’s grade level in school was added. Date of Birth fields were added to the section collecting information about the child’s parents, and a marital status question was added. Parental information has been eliminated from the Child 2 & 3 sections. This section also now only collects information for 3 children, rather than 4, as the average CM household does not contain 4 children. Households containing 4 or more children may provide the needed information on a separate sheet of paper and attach it to the Form 800PR. These additions were requested by staff in the CMU and DFA Field Operations;

- the section collecting information about pregnant women now follows the sections collecting information on the children in the household. This section was additionally revised to request the date of birth of the woman who is pregnant, request information about whether the pregnant woman is a student and, if so, what grade, and, if the pregnant woman is married, request information about if the husband lives in the home and the husband’s date of birth. The field requesting the pregnant woman’s SSN was removed from this section as this information has generally been provided in the first section. If the information is not provided because the person completing the first section of the Form 800PR is not the pregnant woman, CMU workers will contact the household to get the pregnant woman’s SSN. Finally, text was added to this section to collect information about whether the pregnant woman would like help with unpaid medical bills and would like to apply for retroactive medical assistance. These revisions were requested by staff in the CMU and DFA Field Operations;

- in the section collecting information about other income, a field to collect the state from which Unemployment Income is being provided was added. A field to collect the claim number was added for Social Security income, and the following text was added after the "Other Income" field to help explain what is meant by "other" income: (such as interest/dividends/trusts). These revisions were requested by staff in the CMU and DFA Field Operations;

- the child/adult care expenses was revised to remove reference to adult care expenses, and specify that expenses for children are for legal dependents;

- the "Tell Us About Health Insurance" section was moved from the beginning sections of DFA Form 800PR to near the end of the form. Additionally, the time period for requesting information associated with past health insurance coverage was changed from 6 months to 12 months. DFA needs to know about other health insurance coverage for third party liability, as all available parties must be billed and all resulting payments must be applied to the cost of medical care before DHHS will pay. Expanding the time period from 6 to 12 months in this section, 12 months is the CM/MCPW eligibility period between application and renewal, allows DFA to access any TPL sources that may have become available since application or the last renewal. This section was also expanded to ask the recipient why the insurance coverage ended, if the medical assistance received was from another state, and, if so, which state. Most of these revisions were requested by staff in the CMU and DFA Field Operations; and

- the signature statements text was moved to the last page of the Form 800PR. Additionally, the following statement was added to the "I understand" statements preceding the field for the recipient’s signature: If I choose to Go Green, I understand that this means that I will get future notifications from DFA through my NH EASY account, and I will no longer get paper notices. DFA will email me when I have these notices using the email address I gave above. This text was added to support the addition of the "Go Green" question at the beginning of the Form 800PR and the statewide implementation of NH EASY (see DFA SR 11-09 for more details).

The instructions for this form were updated accordingly.

·   DFA Form 808P, Information Necessary to Support Your Medical Coverage Application, was revised to:

- eliminate the text devoted to the documentation required to prove citizenship and identity. Changes at the federal level and implementation of the Social Security Administration cross-match in August 2010 removes the burden on most applicants to provide original paper proof of citizenship and identity as a condition of eligibility for medical assistance. See SR 10-31 for more details; and

- include a section to collect Social Security numbers (SSN). All Medicaid applicants must provide SSNs as a condition of eligibility.

The associated instructions were updated to replace references to the "Healthy Kids" program with the term Children’s Medicaid (CM). Since this form is only used by PE providers, the Supervisor of the CMU District Office has been provided with the new version of this electronic form and will be sending it to all our PE providers to be used immediately upon receipt.

·   DFA Form 810, Notice of Rights and Responsibilities, and its associated Bosnian and Spanish translations, DFA Forms 810(Bo) and DFA Form 810(Sp), were revised to:

- remove a reference to the "Healthy Kids" program; and

- add a reference to child care assistance in the text listing the programs that do not have a time limit on eligibility, at the request of CDB;

There are no changes in the way this form will be used, so the instructions for this form were not altered and will not be re-released with this SR.

·   DFA Form 811R, Application: Your Rights and Responsibilities, and its associated Bosnian and Spanish translations, DFA Form 811R(Bo) and DFA Form 811R(Sp), were revised to:

- remove a reference to the "Healthy Kids" program;

- child care text, either in association with the assistance received or in regards to providers, was added at the request of CDB to the "Quality Control," "Reporting Changes," and "Attention" sections of the Rights and Responsibilities pages of DFA Form 800. CDB also requested the following new addition to the "Do Not" section: Do not use child care services paid for by DHHS, for employment-related activities not approved by DHHS; and

- the EBT unit requested the following new addition to the "Do Not" section of the Rights and Responsibilities page of DFA Form 800: Do not give your EBT Card PIN out to anyone.

There are no changes in the way this form will be used, so the instructions for this form were not altered and will not be re-released with this SR.

·   at the request of CDB, DFA Form 811S, Application: Statements of Understanding, , and its associated Bosnian and Spanish translations, DFA Form 811S(Bo) and DFA Form 811S(Sp), were revised to add the following new text: I understand that I must only use child care services paid for by DHHS for those employment-related activities approved by DHHS. I may have to reimburse DHHS for those payments made for times I was involved in other, non-approved activities.

There are no changes in the way this form will be used, so the instructions for this form were not altered and will not be re-released with this SR.

·   Food Stamp 130% Reporting Requirements Poster, was revised to remove a reference to the "Healthy Kids" program.

All offices were given instructions to recycle any copies of the forms listed above in their possession, and were provided with a small supply of the new versions to begin using upon receipt. A Certificate of Destruction has been included with this SR.

When offices require additional supplies of all English versions of the forms, use the regular quarterly forms order (QFO) reordering process. Contact the Policy Unit for Spanish and Bosnian versions of the forms that have been translated as needed.

DFA Form 800PEN and DFA Form 808P are electronic forms used primarily by trained PE providers, meaning DHHS provides the electronic forms to the trained PE providers, the PE providers complete the forms electronically, and then print them out as needed. The DFA Supervisor of the CMU was provided with the electronic versions of both the DFA Form 800PEN and DFA Form 808P for release to the CMU’s shared drive and for distribution to trained PE providers.

All forms, English, Spanish, and Bosnian, can also be accessed by DHHS employees via the Family Services database in Lotus Notes.

POLICY MANUAL REVISIONS

Revised Family Assistance Manual Topics

Introduction

PART 109  APPLICATION PROCESS

Section 109.01  Filing an Application

Section 109.03  Processing a Filed Application

Section 109.09  Application for Retroactive Medical Assistance

Section 123.01  Initiation of Medical Assistance

Section 127.01  Interview Sites

PART 131  ELIGIBILITY DETERMINATIONS

Section 131.01  Presumptive Eligibility

PART 135  PROVIDING NOTICES TO INDIVIDUALS

PART 139   NOTICES OF DECISION (NOD)

PART 161  REDETERMINATION/RECERTIFICATION

Section 161.01  Timely Notice

Section 161.05  Processing Redeterminations/Recertifications

Section 161.07  Termination at Redetermination/Recertification

PART 201  PROGRAM REQUIREMENTS

Section 205.01  Children Up To Age 19

Section 205.05   Severely Disabled Children

Section 207.07  Dependent Children Who Are Students

PART 219  CHILDREN UP TO AGE 19

Section 219.03  Required Verification

PART 223  CHILDREN WITH SEVERE DISABILITIES

PART 225  HOME CARE FOR CHILDREN WITH SEVERE DISABILITIES (HC-CSD)

Section 307.01  Eligibility Within Institutions

Section 307.03  Individuals In Designated Receiving Facilities

Section 307.11  Medical Assistance Inmates

Section 309.01  SSN Eligibility and Applicant Notification Requirement

Section 309.05  Completing an Application for an SSN

PART 509  VERIFICATION

PART 511  COMMON TYPES OF INCOME: DEEMED INCOME

PART 601  Table C: FANF Medical Assistance Net Income Limits and Percentages of Poverty Guidelines

PART 603  DEDUCTIONS AND DISREGARDS

Section 603.03  Employment Expense Deduction (EED)

Section 603.05  Child/Dependent Care Deduction

Section 603.09  Other Allowable Deductions: Garnishments

Section 603.11  Verification of Deductions

Section 611.03  Deeming Principles

Section 611.04  Determining Budgetary Units For Medical Assistance Programs

PART 803  NOTIFICATIONS AT APPLICATION

Revised Adult Assistance Manual Topics

Section 155.03 Termination at Redetermination

IMPLEMENTATION

As of June 1, 2012, the CMU is located at 105 Pleasant St., Concord, NH 03301. The mailing address to send applications for CM or Medical Coverage for Pregnant Woman (MCPW) only, is:

NH Department of Health and Human Services

Children’s Medicaid Unit (CMU)

129 Pleasant Street

Concord, NH 03301-9846

The toll free phone number remains unchanged: 1-877-464-2447. The local phone number is now 271-9729, and the fax number is now 271-8604.

The return envelopes for the Central Scanning Unit for the CMU District Office remain the same. The move to the new location took place on June 1, 2012. Notification of the CMU name and location change was sent to all DO #78 cases on May 21, 2012. The letter has been attached for reference.

New NH Medicaid cards will be issued to all current and future recipients of CM. Current recipients will be instructed to discontinue using their "Healthy Kids" cards as of July 1, 2012 via a mailing coordinated by the Office of Medicaid Business and Policy (OMBP) which will be mailed throughout the month of June 2012. The OMBP letter has been attached to this SR for reference, along with the instructions that are being sent with the NH Medicaid cards.

The Children’s Medicaid program will be administered completely within DHHS without the involvement of a third party medical insurance company. Harvard Pilgrim and Northeast Delta Dental may have enrolled providers who are not enrolled with New Hampshire Medicaid. Because CM recipients must receive their medical and dental services from doctors and providers enrolled in NH Medicaid, some CM recipients may need to switch to providers who are enrolled with New Hampshire Medicaid.

The new versions of all DFA Forms must be used immediately upon receipt of the initial supply.

CLIENT NOTIFICATION

Notification of the changes to various He-W 500, 600 and 900 rules to support the Legislature’s decision to move toward Medicaid managed care, and not renew the NHHKC contract, was published in the NH Rulemaking Register, Office of Legislative Services, on March 22, 2012. A public hearing on the amended Administrative Rules was held on April 12, 2012.

OMBP issued the following client notifications:

·   a letter entitled "Dear Families" was generated on May 1, 2012 to the former "Healthy Kids Silver" population to notify them of the changes involved with transitioning to Medicaid. An insert was included with this mailing which listed the phone numbers for clients to call with questions. A sub-group of this mailing, "Healthy Kids Silver" recipients who had never been on any Medicaid program such as "Healthy Kids Gold," additionally received a Fact Sheet with information about Children’s Medicaid, a brochure with a list of all Medicaid covered services, and other informational brochures describing Medicaid services and cards. This sub-group was approximately 10% of the former "Healthy Kids Silver" population; and

·   a letter entitled "New Enrollee" was generated on May 17, 2012 to all families who were found to be eligible for "Healthy Kids Silver" after the "Dear Families’ letter above was issued. An insert was included with this mailing which listed the phone numbers for clients to call with questions and a separate Fact Sheet with information about Children’s Medicaid.

On June 20, 2012, a phone message will be sent out via the DHHS autodialer to the former "Healthy Kids Silver" population to remind them of the changes mentioned in the letters sent in May. The phone message includes Medicaid Client Services phone number in case of questions.

A press release was published on the DHHS website on May 2, 2012 regarding the details of the changes. Additionally, a FAQ section has been added to the DHHS website to help guide applicants through this change.

All Children’s Medicaid recipients will be sent new cards throughout the month of June. Instructions to destroy the "Healthy Kids" card and begin using the Medicaid card on July 1 will be included with the new Medicaid card.

DFA sent out a client letter on May 21, 2012 notifying all clients associated with DO #78 of the name change to the Children’s Medicaid Unit and the new contact information.

All letters sent to clients and the autodialer message has been attached to this SR for reference.

TRAINING

A presentation outlining the new policy and procedures related to Children’s Medicaid was provided on March 28, 2012 to internal stakeholders and on April 19, 2012 to external stakeholders. An informational briefing regarding the new DFA forms and procedures related to Children’s Medicaid was held on May 15, 2012 for all community partners who assist applicants through the application process, and those who determine Presumptive Eligibility.

No other trainings are planned.

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 July 2, 2012. 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/LRB:s