SR 13-13 Dated 02/13

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases revisions to the following forms:

·   DFA Form 800, Application for Assistance, its associated Spanish translation, DFA Form 800(Sp), and the newly translated Nepali version, DFA Form 800(Ne);

·   DFA Form 811R, Application: Your Rights and Responsibilities, its associated Spanish translation, DFA Form 811R(Sp), and the newly translated Nepali version, DFA Form 811R(Ne); and

·   DFA Form 811S, Application: Statements of Understanding, its associated Spanish translation, DFA Form 811S(Sp), and the newly translated Nepali version, DFA Form 811S(Ne).

This SR additionally releases the obsolescence of DFA Form 800(Bo), Bosnian Version of DFA Form 800, DFA Form 811R(Bo), Bosnian Version of DFA Form 811R, and DFA Form 811S(Bo), Bosnian Version of DFA Form 811S.

POLICY AND DESCRIPTION OF REVISIONS MADE TO FORMS

DFA Form 800, Application for Assistance, is an eight-page form (four back-to-back sheets) containing 3 parts:

·   Information related to application and the actual application aspect of DFA Form 800, which is pages 1-4 of DFA Form 800 (two back-to-back sheets);

·   the rights and responsibilities section which must be provided at application. This we call DFA Form 811R, Application: Your Rights and Responsibilities, and it is pages 5-6 of DFA Form 800 (one back to back sheet); and

·   the statements of understanding section which we provide at application. This we call DFA Form 811S, Application: Statements of Understanding, and is pages 7-8 of DFA Form 800 (one back to back sheet).

DFA Form 811R and DFA Form 811S are individual forms that are also provided to applicants and recipients, per policy, separately from DFA Form 800. For example, DFA Form 811R is provided with every redetermination application to ensure that recipients are regularly provided with their Rights and Responsibilities.

In the description of the form changes below, DFA Form 800 is primarily referenced but specific changes to each form are noted separately in parenthesis for reference.

The Office of Special Investigations (OSI) brought to DFA’s attention an incorrect statement on DFA Form 800, page 2. Pursuant to RSA 167:17-a, the Department does not have authority to recover erroneously received cash assistance, child care assistance, or Medicaid when the erroneous receipt of assistance was due to a mistake the Department made in processing the case. However, 7 CFR 273.18 mandates recovery of erroneously received Food Stamp benefits, including those benefits received erroneously due to agency error. Because of this, the following text was revised in DFA Form 800 and its Spanish translation, as indicated by the strikethrough formatting below denoting eliminated text and bold formatting denoting added text:

You are required to pay back any benefits or services received in error, regardless of whether we made a mistake in processing your case or you made a mistake in the information you provided, or failed to provide, to us. If you get Food Stamps, you must also pay back any benefits you received in error if we made a mistake in processing your case.

Current Department procedures as described in Family Assistance Manual (FAM) 623, RECOUPMENT OF MEDICAL ASSISTANCE, and Food Stamp Manual (FSM) 621, RECOUPMENT/REPAYMENT OF ASSISTANCE, require no changes. FAM 621, RECOUPMENT/REPAYMENT OF ASSISTANCE, and AAM 631, RECOUPMENT OF FINANCIAL ASSISTANCE, were updated accordingly.

With the passage of RSA 167:4-c and impending implementation of 42 USC 1396w, OSI and DHHS Legal Services brought to DFA’s attention that additional edits would be required to DFA Form 800, DFA Form 811R, and DFA Form 811S, to further clarify:

·   how an applicant or recipient’s SSN will be used (DFA Form 800, page 1);

·   the various resources, tools, and computer matching programs that will be used to verify the accuracy of information that an applicant or recipient has provided or failed to provide to the Department (DFA Form 811R and page 6 of DFA Form 800);

·   that an applicant or recipient’s signature on DFA Form 800 or DFA Form 811S permits DHHS and any contracted third party entity to verify the applicant or recipient’s income, identity, and assets, and the income, identity, and assets of any other person whose income, identity, and assets are required to determine eligibility for the assistance the applicant or recipient is requesting (DFA Form 811S and page 7 of DFA Form 800);

·   that that applicant or recipient’s failure to give permission to conduct these verifications or revoking permission to conduct these verifications will result in denial or termination of assistance (DFA Form 811S and page 7 of DFA Form 800);

·   that an applicant or recipient’s signature on DFA Form 800 or DFA Form 811S authorizes DHHS to obtain verification that the applicant or recipient or anyone in the applicant or recipient’s assistance group meet the eligibility requirements for assistance, and authorizes release of such information, including medical records from medical providers, to DHHS (DFA Form 811S and pages 7-8 of DFA Form 800); and

·   that the applicant or recipient’s authorization to release information or medical records to DHHS remains in effect for as long as the applicant or recipient or anyone in the applicant or recipient’s assistance group receives any kind of DHHS assistance, including nursing home care (DFA Form 811S and pages 7-8 of DFA Form 800).

A new student status column was additionally added to Section B of the application (page 3 of DFA Form 800), text was edited to further delineate the statements of understanding that are associated with the specific programs and the font size of these statements was increased for readability (DFA Form 811S and pages 7-8 of DFA Form 800).

DFA Form 800(Bo), Bosnian Version of DFA Form 800, DFA Form 811R(Bo), Bosnian Version of DFA Form 811R, and DFA Form 811S(Bo), Bosnian Version of DFA Form 811S, are obsolete with the release of this SR. The Office of Minority Health and Refugee Affairs (OMHRA) has informed DFA that the Bosnian population in NH has greatly diminished. Because of this, OMHRA indicated that there is no longer a need for DFA forms to be translated into Bosnian. As such, DFA Form 800(Bo), DFA Form 811R(Bo), and DFA Form 811S(Bo) will not be updated with the changes made to the English versions but instead are obsolete. A Certificate of Destruction has been included with this SR.

Workers should continue to use the old English and Spanish versions of DFA Form 800, DFA Form 811R, and DFA Form 811S until the supply is exhausted. A small supply of the new Nepali translations will be sent to all offices in the near future and can be used immediately upon receipt when needed. Once the current supply of the English version of DFA Form 800, DFA Form 811R, and DFA Form 811S is exhausted, the new version of each form will be available from the DHHS warehouse in the usual manner, via the Quarterly Forms Order (QFO). The Spanish and Nepali versions may be reordered by contacting the Policy Unit Supervisor directly. The forms are also available electronically, for Department staff only, on the Lotus Notes Family Services Database. DFA Form 800 and DFA Form 811R are also available on the DHHS website.

POLICY MANUAL REVISIONS

Revised Family Assistance Manual Topics

PART 511  COMMON TYPES OF INCOME: LUMP SUM INCOME (INCOME)

PART 621  RECOUPMENT/REPAYMENT OF ASSISTANCE

Revised Adult Assistance Manual Topics

PART 631  RECOUPMENT OF FINANCIAL ASSISTANCE

IMPLEMENTATION

District Office staff must deplete the old English and Spanish versions of DFA Form 800, DFA Form 811R, and DFA Form 811S before the new version is printed. A small supply of the new Nepali translations will be sent to all offices in the near future and can be used immediately upon receipt when needed. Once the current supply of the English version of DFA Form 800, DFA Form 811R, and DFA Form 811S is exhausted, the new version of each form will be available from the DHHS warehouse in the usual manner, via the QFO. The Spanish and Nepali versions may be reordered by contacting the Policy Unit Supervisor directly. The forms are also available electronically, for Department staff only, on the Lotus Notes Family Services Database. DFA Form 800 and DFA Form 811R are also available on the DHHS website.

CLIENT NOTIFICATION

No special 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 April 1, 2013. 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