SR 14-31 Dated 12/14

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases revisions to the following forms:

·      DFA Form 77a, Financial Assistance to Needy Families (FANF), its Nepali and Spanish translations, DFA Form 77a(Ne) and DFA Form 77a(Sp), and its associated instructions, DFA Form 77a(i);

·      DFA Form 776(i), Instructions for DFA Form 776;

·      DFA Form 777, NH EASY Provider Enrollment, and its associated instructions, DFA Form 777(i); and

·      DFA Form 786, Inmate Application Cover Sheet, and its associated instructions, DFA Form 786(i).

POLICY

Begin using the latest versions of DFA Form 77a once the current supply has been depleted. DFA Form 777 is electronic and therefore is immediately available in its latest version, when needed. Begin using the new version of DFA Form 786 upon receipt.

DESCRIPTION OF REVISIONS MADE TO FORMS

DFA Form 77a, Financial Assistance to Needy Families (FANF)

DFA Form 77a, Financial Assistance to Needy Families (FANF), was primarily revised to remove text that alluded to the provision of financial assistance being linked to the provision of medical assistance, as that is no longer accurate (see SR 14-04, dated January 2014 for more information). This change entailed a revision to the title of the form and removal of a paragraph about medical assistance within the pamphlet. Additionally, the form was modified to:

·      Add the following text about the use of cash assistance from an EBT card, as released in SR 14-05, dated January 2014, to the “What Are My Rights?” section of the pamphlet:

If you choose to get your cash grant through an EBT card, you can not use your EBT card, or cash from your EBT card, at a banned business, which are businesses in which greater than 50% of visible inventory is alcohol, any gaming establishment, or businesses in which greater than 50% of visible inventory being sold or rented is material considered adult-oriented entertainment per RSA 650:1,III. Using your EBT card or cash from your EBT card at a banned business will result in a cash penalty per RSA 167:7-b and He-W PART 608.

·      Add the following new “Be Educated” text to the “What Are My Responsibilities?” section of the pamphlet:

Be Educated

You must read all notices you get from us and respond within the timeframes in those notices. It is your responsibility to know the eligibility requirements for the programs of assistance you get, and to follow the rules of the program.

·      Add the following clarifying text to the “Report Any Changes” paragraph in the “What Are My Responsibilities?” section of the pamphlet:

Delays in reporting and verifying changes may result in your getting benefits or services in error. You must pay back any benefits or services received in error, regardless of whether you made a mistake in the information you gave, or failed to give, to us.

The instructions were updated accordingly, and the Nepali and Spanish versions were retranslated to reflect these changes. The current versions of this form must be used until the supply is exhausted, at which point the new version will be printed. The English version of DFA Form 77a is available in the DHHS Warehouse and can be ordered using current forms reordering procedures, via the Quarterly Forms Order (QFO). The translated forms can be reordered by contacting the Supervisor of the Policy Development Unit. All versions of this form are also available electronically, for Department staff only, on the Lotus Notes Family Services Database. The latest versions of the forms are available to the public on the following DHHS websites: http://www.dhhs.nh.gov/dfa/apply.htm and http://www.dhhs.nh.gov/dfa/publications.htm

DFA Form 776(i), Instructions for DFA Form 776

DFA Form 776(i), Instructions for DFA Form 776, were updated to better explain the work flow of this form. Because these changes were merely clarifications, the form will retain it’s original SR and release date as identifiers, although the original July 2013 date now also includes “Rev 12/14.” Usually a revision entails only a phone number or address change, but because these changes were more extensive, the instructions are being released in this SR so that the office paper forms manuals can be updated with the new version now. This form is also available electronically, for Department staff only, on the Lotus Notes Family Services Database.

DFA Form 777, NH EASY Provider Enrollment

DFA Form 777, NH EASY Provider Enrollment, was primarily revised to update the address to which the form should be sent by providers/organizations when requesting enrollment in NH EASY (see SR 13-05, dated July 2013 for more information). The instructions for this form were updated accordingly and to more clearly articulate the workflow process for this form. DFA Form 777 is electronic so is immediately available for use, for Department staff only, on the Lotus Notes Family Services Database.

DFA Form 786, Inmate Application Cover Sheet

DFA Form 786, Inmate Application Cover Sheet, is an internal document used by DHHS and the NH Department of Corrections (DOC) as well as County jail staff to assist in collecting the medical assistance application documents for inmates who:

·      become inpatients of a medical institution while incarcerated (for DOC staff only); or

·      have an approaching release date from the correctional facility (for both DOC and County jail staff).

The form was primarily revised to remove references to certain documentation that is no longer needed from DOC/County jail staff now that NH is offering medical coverage through the NH Health Protection Program (NHHPP/NHHPP-M). Since many inmates will be eligible for NHHPP/NHHPP-M, all the documents solely related to the disability-related medical assistance programs, such as Aid to the Permanently and Totally Disabled (APTD), Aid to the Needy Blind (ANB), or Medicaid for Employed Adults with Disabilities (MEAD), were eliminated from the form. Additionally, because of the eased verification requirements associated with the medical assistance programs using modified adjusted gross income (MAGI) in the eligibility determination process, the documents listed on the form that were associated with certain types of verification, such as identity and citizenship or pregnancy, could also be eliminated. See DFA SR 14-04, dated January 2014 for more information about the medical assistance programs using MAGI in the eligibility determination process, and DFA SR 14-28, dated August 2014 for more information about NHHPP/NHHPP-M.

The instructions for DFA Form 786 were updated accordingly and to better articulate the workflow process associated with this form. Copies of the old version of DFA Form 786 stored in the District Offices or at the DOC/County jail may be recycled upon receipt of this SR, and the new version used immediately. DFA Form 786 is available in the DHHS Warehouse and may be ordered using current forms reordering procedures, via the QFO. Both forms are available electronically, for Department staff only, on the Lotus Notes Family Services Database. A Certificate of Destruction has been included with this SR.

POLICY MANUAL REVISIONS

Revised Adult Assistance Manual Topics

PART 175  MEDICAL ASSISTANCE FOR INMATES

Section 175.01  Inmates With an Approaching Release Date

Section 175.03  Inmates Who Become Inpatients in a Medical Facility While Incarcerated

Revised Medical Assistance Manual Topics

PART 175  MEDICAL ASSISTANCE FOR INMATES

Section 175.01  Inmates With an Approaching Release Date

Section 175.03  Inmates Who Become Inpatients in a Medical Facility While Incarcerated

Section 305.07  Medical Assistance: Inmates

IMPLEMENTATION

DFA Form 777 is electronic and is therefore immediately available in its latest version, when needed. The new version of DFA Form 786 may be used immediately upon receipt; a small supply has been sent to the Seacoast, Manchester, and Concord District Offices. Other offices or facilities may contact the Warehouse for a supply and/or print a copy from the Lotus Notes Family Services Database when needed. Old versions of DFA Form 786 may be recycled. A Certificate of Destruction has been included with this S. The current version of DFA Form 77a must be used until the supply has been exhausted, at which point the new version will be printed.

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 February 2, 2015. 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, Medical Assistance, and Forms Manuals.

DFA/JBV:s