SR 14-17 Dated 09/14

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases changes to the following forms associated with the policies released in DFA SR 14-04, dated January 2014 and DFA SR 14-28, dated August 2014:

·      DFA Form 757, How Your Benefits Will Change When You Go To Work, its Nepali and Spanish translations, DFA Form 757(Ne) and DFA Form 757(Sp), and its associated instructions, DFA Form 757(i);

·      DFA Form 800A, DFA Programs & Services Guide, its Nepali and Spanish translations, DFA Form 800A(Ne) and DFA Form 800A(Sp), and its associated instructions, DFA Form 800A(i); and

·      DFA Form 800V, Examples of Acceptable Proofs, its Nepali and Spanish translations, DFA Form 800V(Ne) and DFA Form 800V(Sp), and its associated instructions, DFA Form 800V(i).

This SR additionally releases the obsolescence of the following forms:

·      DFA Form 63, Report of Information Change, and its associated instructions;

·      DFA Form 757(Bo), Bosnian Version of DFA Form 757;

·      DFA Form 800A(Bo), Bosnian Version of DFA Form 800A; and

·      DFA Form 800V(Bo), Bosnian Version of DFA Form 800V.

Finally, in an unrelated change, additional text is being added to Medical Assistance Manual (MAM) PART 301, Residency, to clearly indicate that an individual aged 18-22 and a full time student in NH is not considered a resident of NH when determining eligibility for medical assistance if:

·      neither of the individual’s parents live in NH;

·      the student is claimed as a tax dependent by someone in another state; and

·      the student is applying on his or her own behalf.

Individuals who meet the criteria above are considered to be in NH temporarily and are not considered to be NH state residents during the medical assistance eligibility determination process. This has always been the policy in NH, however the policy pages did not clearly articulate this policy.

POLICY

The following DFA Forms have been updated to incorporate changes released in DFA SR 14-04, dated January 2014 and DFA SR 14-28, dated August 2014:

·      DFA Form 757, How Your Benefits Will Change When You Go To Work, its Nepali and Spanish translations, DFA Form 757(Ne) and DFA Form 757(Sp), and its associated instructions, DFA Form 757(i);

·      DFA Form 800A, DFA Programs & Services Guide, its Nepali and Spanish translations, DFA Form 800A(Ne) and DFA Form 800A(Sp), and its associated instructions, DFA Form 800A(i); and

·      DFA Form 800V, Examples of Acceptable Proofs, its Nepali and Spanish translations, DFA Form 800V(Ne) and DFA Form 800V (Sp), and its associated instructions, DFA Form 800V(i).

The three forms listed above were updated to:

·      Reflect the new names of the categories of Medicaid that use modified adjusted gross income (MAGI) to determine income, as released in SR 14-04, dated January 2014;

·      Modify text to reflect that interviews may be required, if this topic was mentioned in the form, as eligibility interviews are not required to determine eligibility for the MAGI categories of Medicaid;

·      Refer to the new New Hampshire Health Protection Program (NHHPP/NHHPP-M) medical coverage category, if pertinent. See SR 14-28, dated August 2014 for more information about NHHPP/NHHPP-M; and

·      Incorporate changes to website addresses and phone numbers, as appropriate, and update the instructions for the forms.

Any revisions to the forms that were made beyond the description above have been noted in the Description of Additional Revisions Made to DFA Forms 800A & 800V section below.

The three forms described above must be used until the current supply is exhausted, at which point the new version will be printed. These forms are available in the DHHS Warehouse and can be ordered using current forms reordering procedures, via the Quarterly Forms Order (QFO). The forms are also available electronically, for Department staff only, on the Lotus Notes Family Services Database, and available to the public on the following website: http://www.dhhs.nh.gov/dfa/apply.htm . The Spanish and Nepali versions of the three forms can be reordered by contacting the Supervisor of the DFA Policy Unit.

Additionally, the following forms are obsolete upon the release of this SR:

·      DFA Form 63, Report of Information Change, and its associated instructions, as requested by Division of Client Services (DCS) Field Support, due to lack of use and the form having been primarily replaced by scanning of forms, such as DFA Form 470, Change Report Form, or DFA Form 65, Client Statement, into New HEIGHTS and/or data entry of the information from any form reporting a change into New HEIGHTS.

·      The following Bosnian forms because the Office of Minority Health and Refugee Affairs (OMHRA) has informed DFA that the Bosnian population in NH has greatly diminished and there is no longer a need for DFA forms to be translated into Bosnian:

-     DFA Form 757(Bo), Bosnian Version of DFA Form 757;

-     DFA Form 800A(Bo), Bosnian Version of DFA Form 800A; and

-     DFA Form 800V(Bo), Bosnian Version of DFA Form 800V.

A Certificate of Destruction has been included with this SR.

UNRELATED POLICY CLARIFICATION

Students and NH Residency

Additional text has been added to MAM PART 301, Residency, to clearly indicate that an individual aged 18-22 and a full time student in NH is not considered a resident of NH when determining eligibility for medical assistance if:

·      neither of the individual’s parents live in NH;

·      the student is claimed as a tax dependent by someone in another state; and

·      the student is applying on his or her own behalf.

Individuals who meet the criteria above are considered to be in NH temporarily, and are not considered to be NH state residents during the medical assistance eligibility determination process.

DESCRIPTION OF ADDITIONAL REVISIONS MADE TO DFA FORMS 800A & 800V

DFA Form 800A, DFA Program & Services Guide, was additionally revised to:

·      update the Food Stamp Program resource limits for both target and non-target households as released in DFA SR 12-25, dated October 2012 and DFA SR 14-32, dated October 2014;

·      concentrate on only the cash programs offered under the Financial Assistance to Needy Families (FANF) Cash Program header and provide further clarifications in the descriptions of the various FANF categories listed, as requested by the NH TANF Program Specialist;

·      add the following proofs to the Some Programs May Also Require Proof Of: section: FANF deprivation, income deduction, and application for other benefits for which the applicant or other members in the household may be eligible;

·      add text to the How Are Benefits Delivered? section about the banned use of EBT cards and cash obtained from the EBT cards, per SR 14-05, dated January 2014, and to add clarifications about the availability of web-based billing in the NH Child Care Scholarship subsection, at the request of the NH TANF Program Specialist; and

·      add that Failure to keep your appointment could result in lower benefits, your benefits being denied, or your benefits ending to the What We Expect from You Section to address certain Food Stamp Program requirements for notifying Food Stamp applicants and recipients of this information, at the request of the NH Food Stamp Program Specialist.

DFA Form 800V, Examples of Acceptable Proofs, was additionally revised to add the following:

·      statement to the lead-in text on the form at the request of the NH Food Stamp Program Specialist to satisfy certain Food Stamp Program guidelines: Note: An Interview is always required for Food Stamps;

·      statement to the SSN section at the request of the NH Food Stamp Program Specialist to satisfy certain Food Stamp Program guidelines: If someone in your household is not applying for benefits s/he does not have to provide a Social Security Number or prove that s/he has applied for one; and

·      clarifications to the Expenses section of the form: Shared Shelter Statement/Form 768 (see DFA SR 14-15 for more details) and Fuel Assistance Award Letter (see DFA SR 14-26 for more details).

POLICY MANUAL REVISIONS

Revised Adult Assistance Manual Topics

PART 141   ACTIONS ON CHANGES

PART 153   DESK REVIEWS

Revised Family Assistance Manual Topics

PART 147   ACTIONS ON CHANGES

PART 159   DESK REVIEWS

Revised Food Stamp Manual Topics

PART 147   ACTIONS ON CHANGES

Revised Medical Assistance Manual Topics

PART 143   ACTIONS ON CHANGES

PART 155   DESK REVIEWS

PART 301   RESIDENCY

Section 301.03   How to Determine Residency for Medical Assistance

Section 301.07   Out-of-State Recipient Moves into New Hampshire

IMPLEMENTATION

The current version of DFA Form 757, DFA Form 800A, and DFA Form 800V, must be used until the supply is exhausted, at which point the new versions will be printed. These forms are available in the DHHS Warehouse and can be ordered using current forms reordering procedures, via the QFO. The forms are also available electronically, for Department staff only, on the Lotus Notes Family Services Database, and available to the public on the following website: http://www.dhhs.nh.gov/dfa/apply.htm. The Spanish and Nepali versions of the three forms can be reordered by contacting the Supervisor of the DFA Policy Unit.

The obsoletion of DFA Forms 63, DFA Form 757(Bo), DFA Form 800A(Bo), and DFA Form 800V(Bo) are effective upon the release of this SR. Recycle all versions of these forms stored in any facility. A Certificate of Destruction has been included with the SR.

The NH residency policy clarification involving students entering NH from other states for educational purposes is current policy. However, the MAM will reflect this more clearly after the September 26, 2014 tivoli.

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 September 29, 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, Family Assistance, Food Stamp Assistance, Medical Assistance, and Forms Manuals.

DFA/JBV:s