SR 14-08 Dated 01/14

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases updated application processes that were originally released in SR 13-06, dated October 1, 2013, to:

·      incorporate the mandates of the Affordable Care Act (ACA); and

·      simplify application processing procedures.

ACA Mandates

The ACA mandates that individuals who apply for medical assistance (MA) must first be evaluated for eligibility under one of the MAGI-related MA categories, and only if the individual cannot be included in a MAGI-related MA category is the individual evaluated for eligibility under another category of MA offered by the state (see DFA SR 14-04, effective January 1, 2014 for more information on MAGI-related MA categories). Although most individuals with a blind or disabled medical approval cannot receive Medicaid in a MAGI category, and therefore eligibility for a MAGI category of assistance will not be evaluated while a disability approval is active, applicants or recipients without an approved medical disability can be evaluated for eligibility for medical assistance in a MAGI category of assistance while awaiting a disability approval. For example, a new applicant may be determined eligible for Parent/Caretaker Relative MA, a MAGI category of medical assistance, while awaiting an APTD disability approval, a non-MAGI category of medical assistance. However, once the disability is approved, MAGI medical assistance is terminated, and APTD medical assistance, if the individual is otherwise eligible for it, opens. Exception: Children with Severe Disabilities (CSD) medical assistance is a MAGI category of assistance, and MAGI eligibility rules are applied to individuals applying for or receiving this type of medical assistance.

Simplified Application Processing Procedures

Two inserts were created for each of the applications, as follows, to collect information needed to determine eligibility for the MAGI or non-MAGI categories of assistance (depending upon the application used) and reduce District Office worker follow-up contact with applicants to collect missing information needed in the MA eligibility determination process:

·      new DFA Form 800 Insert, Medical Assistance for Children, Pregnant Women and Parent/Caretaker Relatives Insert, was created to be supplied with DFA Form 800, Application for Assistance. The new DFA Form 800 Insert is used for individuals who wish to apply for any category of assistance administered by DFA, including medical assistance. The new insert collects all the MAGI-related MA information not currently collected in the DFA Form 800. This insert is temporary; when DFA Form 800 is next revised, it will collect all the information needed for all categories of medical assistance in one document.

·      new DFA Form 800MA Insert, Medical Assistance for Children, Pregnant Women and Parent/Caretaker Relatives, was created to be supplied with DFA Form 800MA, Application for Health Coverage & Help Paying Costs. The new DFA Form 800MA Insert is used for individuals who wish to apply for all categories of MA offered by NH (MAGI and non-MAGI). The new insert collects all the non-MAGI-related MA information not currently collected in the DFA Form 800MA. This insert is temporary; when DFA Form 800MA is next printed, this insert will be printed as part of the DFA Form 800MA, and then no additional document will need to be provided to applicants. Until the new version of DFA Form 800MA is printed, use this insert along with DFA Form 800MA.

New DFA Form 800 Insert and new DFA Form 800MA Insert were created to support the policy change released in this SR, as follows:

·      New DFA Form 800 Insert supplements DFA Form 800 to allow individuals to provide eligibility information that is not already collected on DFA Form 800, but is required for the MAGI-related MA categories and the Federal Facilitated Marketplace (FFM). Information collected on new DFA Form 800 Insert will be electronically transferred to the FFM for those individuals who do not qualify for MA or who opened for In and Out medical assistance. Individuals who do not wish to apply for MA, or do not qualify for MA under a MAGI-related category, are not required to complete DFA Form 800 Insert.

·      New DFA Form 800MA Insert supplements DFA Form 800MA to allow individuals to provide eligibility information which is not already captured on DFA Form 800MA, for the following MA categories:

-     State Supplement Program (SSP): Aid to the Needy Blind (ANB), Aid to the Permanently and Totally Disabled (APTD), and Old Age Assistance (OAA);

-     Home and Community-Based Care (HCBC) Services;

-     Home Care for Children with Severe Disabilities (HC-CSD);

-     Nursing Facility (NF) Services;

-     Medicaid for Employed Adults with Disabilities (MEAD); and

-     Medicare Savings Program (MSP): Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB); and Qualified Disabled and Working Individual (QDWI) programs.

Both DFA Form 800 Insert and DFA Form 800MA Insert must be returned with a signed corresponding application. These inserts cannot be used on their own to apply for any program of assistance. Instructions were created for DFA Form 800 Insert and DFA Form 800MA Insert accordingly.

Additionally, DFA Form 800 and DFA Form 800MA were also revised to support the policy change released in this SR and the creation of the inserts, as follows:

·      DFA Form 800 will continue to be provided to anyone requesting a paper application for any DFA programs, including medical assistance. However, DFA Form 800 was revised to instruct individuals applying for MA for a child, pregnant women, or parent/caretaker relative of a child, to complete new DFA Form 800 Insert and return it along with the signed DFA Form 800 to their local DO. The applicant is notified that their signature on DFA Form 800 indicates that the information obtained on DFA Form 800 Insert is also true and correct to the applicant’s best knowledge; and

·      DFA Form 800MA will continue to be provided to individuals requesting a paper application who are only interested in applying for MA. This form was revised to:

-     direct individuals who are seeking MA and are elderly, blind, disabled, in need of home care or nursing facility services, an employed adult with disabilities, or in need of help paying their Medicare premium, to complete DFA Form 800MA Insert, as well as DFA Form 800MA;

-     instruct individuals who are completing DFA Form 800MA Insert to return it, along with DFA Form 800MA, to their local DO, as opposed to the Centralized Medicaid Unit (CMU), and notify the individual that an interview and proof of their household circumstance is required when applying for these non-MAGI categories of assistance;

-     notify individuals that their signature on DFA Form 800MA indicates that the information obtained on DFA Form 800MA Insert, as well as any appendices, is also true and correct to the applicant’s best knowledge; and

-     to incorporate the additional tax questions and specification of whom to include in a household, which aligns with DFA Form TAX INFO(T), Rede Request for Tax Info, released in DFA SR 14-09.

In a related change, DFA Form 800P, Application for Children’s Medicaid (CM) and Medical Coverage for Pregnant Women (MCPW), its associated Nepali version, DFA Form 800P(Ne), its associated Spanish version, DFA Form 800P(Sp), and its associated instructions, DFA Form 800P(i), are obsolete with the release of this SR. Note: Despite that this application is now “obsolete,” all versions cannot be collected from the many places in the community where they may be stocked. As such, District Office workers must continue to act upon any DFA Form 800P applications received as if the person had applied on DFA Form 800MA; no DFA Form 800P received should be rejected, and no applicant who has applied on DFA Form 800P should be asked to complete any other application in lieu of the DFA Form 800P that was completed. This may mean follow-up contact is necessary with the applicant to collect any MAGI-related information needed to determine eligibility.

POLICY

Determine medical assistance (MA) eligibility under the MAGI-related categories first, unless the individual has an active disability approval. If an individual does not qualify for MA under a MAGI-related category, or if the individual has an active disability approval, determine if the individual is eligible for MA under a non-MAGI category of MA. Individuals without an active disability approval can be evaluated for eligibility for medical assistance in a MAGI category of assistance while awaiting a disability approval. For example, a new applicant may be determined eligible for Parent/Caretaker Relative MA while awaiting an APTD disability approval. However, once the disability is approved, MAGI medical assistance is terminated, and APTD medical assistance, if the individual is otherwise eligible for it, opens. Exception: Children with Severe Disabilities (CSD) medical assistance is a MAGI category of assistance, and MAGI eligibility rules are applied to individuals applying for or receiving this type of medical assistance.

Continue to provide DFA Form 800 to anyone interested in applying for DFA programs, who wishes to complete a paper application. Include DFA Form 800 Insert along with DFA Form 800 to individuals who wish to apply for MA along with other DFA programs, and may be eligible for MA under a MAGI-related group. Instruct individuals applying for MA for a child, pregnant women, parent, or caretaker relative of a child to complete DFA Form 800 Insert, and return both DFA Form 800 and DFA Form 800 Insert to their local District Office (DO). Individuals who are eligible for MA under a MAGI-related category do not need to participate in an eligibility interview to complete the application process for MAGI-related MA, however individuals are required to participate in an eligibility interview to complete the application process for other DFA programs. Individuals found eligible for MA under a MAGI-related category, but are required to participate in an eligibility interview to complete the application process for other DFA programs, do not have to wait until the eligibility interview is completed prior to receiving MAGI-related MA.

Provide DFA Form 800MA and DFA Form 800MA Insert to individuals who are interested in applying for MA only and wish to complete a paper application. Instruct individuals who are elderly, blind, disabled, in need of home care or nursing facility services, an employed adult with disabilities or in need of help paying their Medicare premium to complete DFA Form 800MA Insert, and return both DFA Form 800MA and DFA Form 800MA Insert to their local DO. These individuals may be required to participate in an eligibility interview, per current policy.

RELATED POLICY CLARIFICATION

The application filing date for applications received through CMS Account Transfer from the Federally Facilitated Marketplace (FFM) is the date the application was signed at the FFM, regardless of the date the application is actually transferred to NH from the FFM for an eligibility determination. The FFM only transfers applications for medical assistance that have been assessed by the FFM as potentially eligible for NH Medicaid, or if the applicant requests a full state Medicaid eligibility determination.

Note: Per current policy, applications received via any of the following methods will have an application filing date as follows:

·      Through NH EASY – the application filling date is the date the application is received by the DO, if received during business hours (8:00 am to 4:30 pm) on a day that the DO is open for business. If the application is received after business hours or on a day when the DO is closed for business, the application filing date is the next day the DO is open for business.

·      Via paper applications mailed in or hand-delivered – the application filling date is the date the application is received by the DO, if received during business hours on a day that the DO is open for business. If the application is received after business hours or on a day when the DO is closed for business, the application filing date is the next day the DO is open for business.

·      Via telephone application – the application filing date is the date the phone application is completed. This type of application is only received at a time when the DO is open for business.

DESCRIPTION OF NEW DFA FORM 800 INSERT

New DFA Form 800 Insert, Medical Assistance for Children, Pregnant Women and Parent/Caretaker Relatives Insert, is a four page double-sided form distributed in conjunction with DFA Form 800, Application for Assistance, and was designed to capture all eligibility information for the MAGI-related MA categories. DFA Form 800 Insert contains all questions located on DFA Form 800MA, Application for Health Coverage & Help Paying Costs, and collects the necessary information that must be forwarded to the FFM. Individuals applying for MA for a child, pregnant women, parent or caretaker relative of a child are instructed to complete DFA Form 800 Insert and return it along with the signed DFA Form 800 to their local DO.

This form must be completed in conjunction with DFA Form 800 to apply for MA under the MAGI-related categories. The applicant’s signature on DFA Form 800 indicates that the information obtained on DFA Form 800 Insert is also true and correct to the applicant’s best knowledge. If this form is returned without a corresponding DFA Form 800, the individual is not considered to be an applicant for any DFA programs. It is not necessary to provide DFA Form 800 Insert to individuals who do not wish to be evaluated for MA.

DFA Form 800 Insert will be translated into Spanish and Nepali. Instructions for DFA Form 800 Insert were created accordingly.

An initial supply of DFA Form 800 Insert was distributed to all DOs as follows:

·      50 to Littleton, Berlin, Conway.

·      100 to Claremont, Concord, Keene, Laconia, Manchester, Southern, Seacoast, Rochester.

·      150 to the Centralized Medicaid Unit, Long Term Care Unit and to DCS Client Services.

When supplies are low, reorder using current forms reordering procedures, via the Quarterly Forms Order (QFO). This form is also available electronically, for Department staff only, on the Lotus Notes Family Services Database, and can be downloaded from the DHHS website at http://www.dhhs.nh.gov/dfa/apply.htm, and http://www.dhhs.nh.gov/dfa/forms.htm.

DESCRIPTION OF NEW DFA FORM 800MA INSERT

New DFA Form 800MA Insert, Additional Requested Information to Determine Eligibility for Other Medical Assistance or Services, is a single page double-sided form distributed in conjunction with DFA Form 800MA, Application for Health Coverage & Help Paying Costs. Individuals who are elderly, blind, disabled, in need of home care or nursing facility services, an employed adult with disabilities, or in need of help paying their Medicare premium are instructed to complete DFA Form 800MA Insert, and return both DFA Form 800MA and DFA Form 800MA Insert to their local DO, as opposed to CMU. Applicants are also notified that an interview and proofs are required as part of the application process for the non-MAGI categories of assistance. DFA Form 800MA Insert was designed to capture all eligibility information for MA under the following categories that is not already collected on DFA Form 800MA:

·      State Supplement Program (SSP) Medical Assistance: Aid to the Needy Blind (ANB), Aid to the Permanently and Totally Disabled (APTD), and Old Age Assistance (OAA);

·      Home and Community-Based Care (HCBC) services;

·      Home Care for Children with Severe Disabilities (HC-CSD) services;

·      Nursing Facility (NF) Services;

·      Medicaid for Employed Adults with Disabilities (MEAD); and

·      Medicare Savings Programs: Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB and SLMB 135), and Qualified Disabled and Working Individual (QDWI) programs.

DFA Form 800MA Insert must be completed in conjunction with DFA Form 800MA to apply for MA under the above categories. The applicant’s signature on DFA Form 800MA indicates that the information obtained on DFA Form 800MA Insert is also true and correct to the applicant’s best knowledge. If this form is returned without a corresponding DFA Form 800MA, the individual is not considered to be an applicant for MA. DFA Form 800MA Insert is not needed for individuals who only wish to apply for MA under a MAGI-related category.

DFA Form 800MA Insert will be translated into Spanish and Nepali. Instructions for DFA Form 800MA Insert were created accordingly.

An initial supply of DFA Form 800MA Insert was distributed to all DOs as follows:

·      50 to Littleton, Berlin, Conway.

·      100 to Claremont, Concord, Keene, Laconia, Manchester, Southern, Seacoast, Rochester.

·      150 to the Centralized Medicaid Unit, Long Term Care Unit and to DCS Client Services.

When supplies are low, reorder using current forms reordering procedures, via the QFO. This form is also available electronically, for Department staff only, on the Lotus Notes Family Services Database. Since at the next order of DFA Form 800MA, the insert will be printed as part of the DFA Form 800MA, the insert is not posted as a single document on the DHHS website. However, the full DFA Form 800MA with the insert included can be downloaded from http://www.dhhs.nh.gov/dfa/apply.htm, and http://www.dhhs.nh.gov/dfa/forms.htm.

DESCRIPTION OF REVISIONS MADE TO FORMS AND THE OBSOLETED FORM

Revised Forms

DFA Form 800, Application for Assistance, was revised to instruct individuals applying for MA for a child, pregnant women, or parent/caretaker relative of a child, to complete the New DFA Form 800 Insert, and return it to their local DO along with the signed DFA Form 800. The individual is notified that their signature on DFA Form 800 indicates that the information obtained on DFA Form 800 Insert is also true and correct to the applicant’s best knowledge.

DFA Form 800MA was revised to:

·      reference new DFA Form 800MA Insert, and inform the applicants that if they would like to apply for any additional Medical Assistance programs or services, they must complete the insert and return it to their local DO along with DFA Form 800MA;

·      instruct individuals who are applying for MA programs that are not MAGI related programs to return DFA Form 800MA Insert, along with DFA Form 800MA, to the DO, as opposed to CMU;

·      notify individuals that their signature on DFA Form 800MA indicates that the information obtained on DFA Form 800MA Insert, as well as any appendices, is also true and correct to the applicant’s best knowledge; and

·      incorporate additional tax questions and specification of whom to include in a household, which aligns with DFA Form TAX Info, Rede Request for Tax Info, released in DFA SR 14-09.

The current version of DFA Form 800 and DFA Form 800MA will be used until the supply is exhausted, at which point the new version will be printed. DFA Form 800 and DFA Form 800MA are available in the DHHS Warehouse and can be ordered using current forms reordering procedures, via the Quarterly Forms Order (QFO). These forms are also available electronically, for Department staff only, on the Lotus Notes Family Services Database, and on the DHHS website.

Obsoleted Form

DFA Form 800P, Application for Children’s Medicaid (CM) and Medical Coverage for Pregnant Women (MCPW), its associated Nepali version, DFA Form 800P(Ne), its associated Spanish version, DFA Form 800P(Sp), and its associated instructions, DFA Form 800P(i) are obsolete as of the effective date of this SR. Due to the creation of DFA Form 800MA, Application for Health Coverage & Help Paying Costs, in DFA SR 13-06 dated October 2013, and new DFA Form 800MA Insert, released in this SR, these forms are no longer needed.

All stock of DFA Form 800P should be recycled upon receipt of this SR. NH Citizens requesting medical assistance for children should now be provided with DFA Form 800MA and new DFA Form 800MA Insert. Note: DFA Form 800P will potentially still be in the community for the next several years as DFA has no ability to determine where community applications may be held and/or to get notice to these community providers that the forms are no longer being used. As such, any DFA Form 800Ps that are received in any office must be acted upon as a valid application. Any additional information that is needed must then be requested of the applicant.

POLICY MANUAL REVISIONS

Revised Adult Assistance Manual Topics

PART 109  APPLICATION PROCESS

Revised Family Assistance Manual Topics

PART 109  APPLICATION PROCESS

Section 109.01  Filing an Application

Section 109.03  Processing a Filed Application

Section 109.07  Reuse of Forms 800 and 800HR After Denial or Closing

Section 109.09  Application for Retroactive Medical Assistance

Section 131.01  Presumptive Eligibility

PART 155  ADDITION OF AN INDIVIDUAL

Revised Food Stamp Manual Topics

PART 109  APPLICATION PROCESS

Revised Medical Assistance Manual Topics

PART 109  APPLICATION PROCESS

Section 109.01  Filing an Application

Section 109.03  Processing a Filed Application

PART 115  JOINT APPLICATIONS

PART 121  INITIATION OF MEDICAL ASSISTANCE

Section 129.01  Presumptive Eligibility

IMPLEMENTATION

The policy released in this SR is effective January 1, 2014, or the date DFA Form 800 Inset and DFA Form 800MA Insert are received in the DOs. The new forms can be used immediately upon receipt.

CLIENT NOTIFICATION

No client notification is planned.

TRAINING

No 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 February 3, 2014. 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 Manual, Family Assistance Manual, Food Stamp Manual, Medical Assistance Manual, and Forms Manual.

DFA/LRB:s